Wondering if your client qualifies for the Medicare Extra Help program? This assistance could be life-changing, helping them afford prescription drug coverage and critical medications. What are the income limits for Part D Extra Help, and are there any tools to verify eligibility?
If you plan to discuss prescription drug coverage in an upcoming appointment, take a moment to confirm whether your client qualifies for Medicare Extra Help. This federal program can make a significant difference in their ability to access essential medications prescribed in their treatment plan.
Important: Even if a client doesn’t meet the Medicare Extra Help income limits, they may still qualify for state assistance programs. Eligibility criteria vary by program, so be sure to review both federal and state options to ensure your clients receive the support they need.
Understanding the Medicare Extra Help Program
The Extra Help program, also known as the “Medicare Low-Income Subsidy (LIS) program,” is a collaborative initiative by the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA) to provide financial support to individuals who need assistance with Medicare prescription drug coverage and medication costs.
How Does Extra Help (LIS) Work?
Individuals enrolled in the Extra Help program often receive substantial savings, including:
- No premiums for prescription drug coverage
- No deductibles for prescription drug coverage (for full subsidy recipients)
- Waiver of the Part D late enrollment penalty
- Reduced copays or coinsurance costs
- No more than $4.50 for each generic drug
- No more than $11.20 for covered brand-name drugs
Once total prescription costs reach $8,000, clients pay $0 for each covered drug.
Additionally, if your client receives full Medicaid and participates in the Qualified Medicare Beneficiary (QMB) program, they won’t pay more than $4.60 for each covered prescription.
Members of the Extra Help program also have a monthly Special Enrollment Period to join or switch Medicare Part D plans. Over a year, those on Medicare with Extra Help can save around $5,100, making this program incredibly valuable for eligible beneficiaries!
Who Automatically Qualifies for Medicare Part D Extra Help?
Certain individuals are automatically enrolled in the Low-Income Subsidy (LIS) program and do not need to complete an Extra Help application. Those who automatically qualify include:
- Individuals who are eligible for both Medicare and Medicaid (dual eligibles)
- People receiving Supplemental Security Income (SSI)
- Those enrolled in a Medicare Savings Program
How to Verify Medicare Extra Help Status for Your Clients
Many clients may not know if they qualify for or receive Extra Help (also known as the Low-Income Subsidy, or LIS), even if they applied in the past, as their status may have changed. Before enrolling clients in a prescription drug plan, it’s essential for agents to confirm their Extra Help eligibility. Doing so not only ensures that clients can better afford their medications, but it also demonstrates your dedication to supporting their financial well-being.
Extra Help/LIS Eligibility Requirements
To qualify for Extra Help, individuals must:
- Have Medicare Part A and/or Part B
- Reside in one of the 50 states or the District of Columbia
- Have total savings, investments, and real estate net worth below $34,360 (married) or $17,220 (single), with some exceptions
- Have an annual income under $30,660 (married) or $22,590 (single)
Ways to Verify a Client’s Extra Help Status
Since verifying LIS status can be complex, it may be easier for you to assist directly rather than asking clients to check on their own. Here are five methods to verify their status:
- Use an LIS lookup tool available on the carrier’s portal, if provided.
- Contact the carrier directly to confirm the client’s LIS eligibility.
- Call 1-800-Medicare (1-800-633-4227) for confirmation.
- Guide your client to create or log in to their MyMedicare.gov account and check their LIS status.
- Direct your client to use the “Find Out If You Qualify” tool on SSA.gov.
These tools allow you to check eligibility prior to enrollment, ensuring your client is positioned to receive the support they need.
Will My Client Be Notified of Changes to Their Extra Help Status?
If your client’s Extra Help status changes, they should receive a notification by mail from CMS or the Social Security Administration (SSA). The notice will come in different colors, with each color indicating a specific purpose of the notification.
Medicare Extra Help Status Quick Reference Guide
| Notice | Color of Notice | Who Sends It? | Recipient | Need to Apply or Reapply? |
| Automatically Eligible for Extra Help | Purple | CMS | Receives both Medicare and Medicaid, participates in a Medicare Savings Program, or receives SSI | NO |
| Automatically Eligible for Extra Help with Auto-Enrollment in a PDP | Green or Yellow | CMS | Eligible for both Medicare and Medicaid and currently receives benefits through Original Medicare | NO |
| Social Security LIS & MSP Outreach Notice | N/A | Social Security | Might be eligible for Extra Help | YES |
| Copay Amount Changing | Orange | CMS | Automatically eligible for Extra Help with an upcoming copayment change | NO |
| No Longer Automatically Eligible for Extra Help | Gray | CMS | Previously received Extra Help automatically but is no longer automatically eligible | YES |
Assisting Your Client with Medicare Extra Help Applications
For clients who don’t automatically qualify for the Low-Income Subsidy (LIS), it’s worthwhile to complete a Medicare Extra Help application if they may be eligible. If you believe your client might qualify, you can assist them in applying through the Social Security Administration’s website. Clients can also apply by phone or by visiting their local Social Security office. For additional guidance, they can contact their State Health Insurance Assistance Program (SHIP).
Did you know that CMS estimates around three million Medicare beneficiaries aren’t enrolled in the Medicare Extra Help program despite qualifying? Don’t let your clients miss out—help them access the financial assistance they may be entitled to today!
Not affiliated with or endorsed by Medicare or any government agency.
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