Financial Aid Programs

What is Extra Help?

Part D prescription drug coverage is available for any Medicare beneficiary. Extra Help is a program within Medicare that assists individuals with the cost of their Part D prescription drug plan. Some Medicare beneficiaries with limited resources and income are eligible for the Extra Help program.

What does Extra Help cover?

Extra Help assists eligible beneficiaries with paying for costs associated with their Medicare Part D prescription drug plan, like annual deductibles, monthly premiums and prescription co-payments or coinsurance.

How Much Will You Pay In Extra Help?

With the full Extra Help benefit in 2020, an eligible beneficiary should pay no more than $3.60 for a generic drug (or a brand-name drug treated as a generic) and $8.95 for any other brandname drug. Savings for individuals enrolled in Extra Help are estimated to be about $4,900 per year. Most people who qualify for Extra Help pay nothing, or a reduced amount, for their monthly premium and annual deductible and will pay no more than the LIS drug coverage cost limit.

Medicare enrollees who have full Medicaid coverage, get help from your state Medicaid program paying your Part D premiums, get Supplemental Security Income (SSI) benefits, or live in an institution like a nursing home should automatically qualify for Extra Help.

How to Qualify for Extra Help

Many Medicare beneficiaries qualify for Extra Help and don't even know it.

To qualify for Extra Help:

1) You must be enrolled in a Medicare Part D prescription drug plan.

2) You must reside in one of the 50 states or the District of Columbia.

3) Your annual income must be less than $18,735 for an individual or $25,365 for a married couple living together.* Even those individuals or couples with incomes exceeding the threshold may still be eligible for assistance (for example, if you or your spouse support other family members who live with you, have work-related earnings or live in Hawaii or Alaska).

4) Your resources cannot exceed $14,390 for an individual or $28,720 for a married couple who live together to receive Extra Help.* Resources include: bank accounts, stocks and bonds. Resources do not include: your home, your car, or life insurance policies.

How to Apply for Extra Help

At the Saratoga Medicare Group we are always trying to help our clients lower their medical costs. Feel free to contact us for assistance with applying.

To apply for Extra Help on your own, you must complete Social Security’s Application for Extra Help with

Medicare Prescription Drug Plan Costs (SSA-1020). You can apply in the following ways:

Once you’ve submitted your application, Social Security will review and send a determination letter to inform you whether or not you’ve qualified. As soon as you receive your eligibility determination, you can choose a Medicare Part D prescription drug plan.

Being deemed eligible for Extra Help does not automatically enroll you in a Medicare prescription drug plan. While some beneficiaries with the full Extra Help benefit may be automatically enrolled in a Part D prescription drug plan, it is still important to follow up to ensure that you are enrolled once your Extra Help application is approved. If you are automatically enrolled but do not choose a plan for yourself, the Centers for Medicare and Medicaid Services (CMS) will randomly assign you to a plan.

What If You Don’t Qualify for Extra Help?

If you are not eligible for Extra Help, but are eligible for Medicare, you are still able to enroll in a Medicare Part D prescription drug plan. Contact our office to see how we can help.

Medicare Savings Program

In addition to Extra Help, Medicare has a program called the Medicare Savings Program (MSP). These are state programs that help with other Medicare-associated costs (ex: Medicare Part B’s medical insurance premiums). By filling out an Extra Help application, you are automatically beginning the application process for MSP as well. Your state will contact you in order to complete the MSP application process. If you would like to opt-out of applying for MSP, there is a place to indicate that on your Extra Help application.

EPIC: New York State Pharmaceutical Assistance Program

Contact our office to learn how EPIC can help you pay for your prescription drug costs.

Eligibility

Must be age 65 or older and a New York State resident.

Income eligibility limit: Singles $75,000; Married couples $100,000/year (since 4/1/2014)

No asset test.

Must be enrolled in Medicare Part D.

1) Part D premium assistance

Pays cost of monthly Part D premiums (up to benchmark).

Must have annual income at/below $23,000 year (single)/$29,000 (couple).

2) Coverage gap ("Doughnut Hole" ) assistance

Helps with cost sharing for Part D. Since 2013, EPIC will subsidize the Part D co-insurance year-round, AFTER the member has met the Part D plan's deductible, if any. With EPIC's help,.the member's Part D co-pay will be no higher than $20 per drug; EPIC will pick up the balance.

EPIC Cost Sharing

If Part D co-pay for a drug without EPIC is...

  • EPIC member pays this amount
  • $0-$15
  • $0-3
  • $15.01 – $35
  • $7
  • $35.01 – $55
  • $15
  • > $55
  • $20

EPIC will also pay for Part D excluded drugs in the coverage gap.

Additionally, EPIC will help members enroll into the Part D Low Income Subsidy ("Extra Help") and Medicare Savings Programs.

3) "Special Enrollment Period"

EPIC members are allowed to change Part D plans once a year just because they are in EPIC. Otherwise, most Part D enrollees may only change once a year during the Annual Enrollment Period in the fall.

EPIC has two tiers of coverage

1. Medicare Drug Plans.

These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Private Fee-for-Service plans, and Medical Savings Account plans. You must have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) to join a separate Medicare drug plan.

2. Medicare Advantage Plan (Part C) or other Medicare Health Plan With Drug Coverage.

You get all of your Part A, Part B, and drug coverage, through these plans. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

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