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Medicare Prescription Drug Coverage for Low-Income Beneficiaries

  • June 25th, 2018

A low-income subsidy (called Extra Help) is available to help pay the premiums, deductibles, and co-payments of the Medicare prescription drug benefit. The amount of the subsidy varies depending on income.

To qualify for Extra Help, you must meet the following criteria:

  • Your annual income must be no more than $18,210 for an individual or $24,690 for a married couple living together (in 2018).
  • Your resources must be no more than $14,100 for an individual or $28,150 for a married couple living together (in 2018). Resources do not include your home, car, and personal possessions.

You automatically qualify for Extra Help if you are enrolled in Medicaid (you are a "dual eligible"), you are enrolled in Medicare Savings Programs (MSPs), or you get Supplemental Security Income (SSI).

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Depending on your income, you may receive a full or partial subsidy. Medicare will not pay low-income beneficiaries' premiums for all drug plans, but only those plans that have a premium at or below the "regional benchmark."

If you are dual eligible, enrolled in MSPs, or get SSI, you do not need to apply for the subsidy. Other individuals have to fill out an application in order to see if they qualify for the subsidy. Click here for information on what you need for the application. You can apply online or by phone at 1-800-772-1213 (TTY 1-800-325-0778).

For more information on Extra Help, click here.

What if you're enrolled in both Medicare and Medicaid?

Many low-income individuals have coverage under both Medicare and Medicaid. Medicaid had been covering prescription drugs for these "dual eligibles," but the law changed that. Beginning January 1, 2006, Medicaid stopped covering prescription drugs.

If dual eligibles do not enroll in a plan themselves, the Department of Health and Human Services automatically enrolls them in a plan. If you had original Medicare, you will have been enrolled in a stand-alone drug plan whose premium is at or below the standard plan premium in your area. If you had an HMO or PPO, you will have been enrolled in the lowest premium prescription drug plan offered by that company.

If you are a dual eligible, you should make sure the plan you were assigned covers the drugs you need and the pharmacies you visit. If it doesn't, you will need to choose a different plan. Call 1-800-MEDICARE or go to www.medicare.gov to compare plans.

If you are a dual eligible enrolled in a drug plan that stops covering a drug you need, you can change your drug plan once a month. As noted above, other beneficiaries are locked into their choice for a full year.

 


Last Modified: 06/25/2018

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