Medicare Part D Low Income Subsidy (LIS) / Extra Help

• Prescription drug costs can be overwhelming for many Medicare beneficiaries, especially seniors living on fixed incomes.
• The Medicare Part D Low Income Subsidy program, commonly called Extra Help, was created to reduce the cost of Medicare prescription drug coverage for people who qualify.
• This program may help pay for Medicare Part D premiums, deductibles, copays, coinsurance, and even reduce or eliminate late enrollment penalties.
• Many people qualify automatically through Medi-Cal or other assistance programs, while others may qualify by applying directly through Social Security.

How and Where to Apply for Extra Help

The primary application for Medicare Part D Extra Help is handled through Social Security. Even if someone thinks they may not qualify, it is often worth checking because the income and resource limits change periodically.

Apply for Medicare Extra Help

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Medi-Medi & Low Income Medicare Help

• You may also call Social Security at 1-800-772-1213. TTY users may call 1-800-325-0778.
• People who already have full Medi-Cal benefits, Supplemental Security Income (SSI), or a Medicare Savings Program may automatically qualify for Extra Help without filing a separate application.

What Does Extra Help Pay For?

• Medicare Part D monthly premiums
• Prescription drug deductibles
• Copayments and coinsurance
• Late enrollment penalties
• Some catastrophic prescription drug costs

In some situations, beneficiaries may pay little or nothing for covered prescriptions. However, each Part D plan still has its own formulary, pharmacy network, and prior authorization rules.

The Good: Why Extra Help Can Be Valuable

• Lower out-of-pocket prescription drug expenses
• Reduced or zero Part D premiums
• Special Enrollment Periods allowing plan changes outside the normal enrollment window
• Protection against very high medication expenses
• Reduced financial pressure for seniors on fixed incomes
• Possible help for people who did not enroll in Part D on time and have a penalty

The Bad: What Extra Help Does Not Fix

• It does not mean every drug is automatically covered
• It does not eliminate formulary rules
• Some medications may still require prior authorization
• Step therapy and quantity limits may still apply
• Preferred pharmacy networks can still affect costs
• Plan changes can still be confusing

One common misunderstanding is that “Extra Help” means every medication is automatically free or covered without restrictions. Formularies, network pharmacies, quantity limits, and utilization management rules may still apply.

The Confusing Part:
Extra Help, Medi-Cal, Medicare Savings Programs, and Part D

Extra Help is related to prescription drug costs, but it is not the same thing as Medi-Cal, Medicare Savings Programs, Medicare Advantage, or Medigap. These programs may overlap, but they are not identical.

A person may need to look at several issues at the same time:

• Do they have Medicare only?
• Do they also have Medi-Cal?
• Do they qualify for a Medicare Savings Program?
• Are they enrolled in a standalone Part D plan?
• Are they enrolled in a Medicare Advantage plan that includes drug coverage?
• Are their medications covered on the plan formulary?

That is why this topic often requires more than simply clicking a quote engine. My quote engine is primarily for Medigap comparisons, not Medicare Advantage plan comparisons. For Medicare Advantage, Medi-Cal coordination, Medi-Medi questions, and Extra Help issues, it is usually better to contact me directly or start with the Medi-Medi information page.

Visit the Medi-Medi Medicare & Medi-Cal Page

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Medicare Savings Programs and Medi-Cal

• Many people confuse Extra Help with Medicare Savings Programs or Medi-Cal. These programs may overlap, but they are not always the same thing.
• Some Medicare Savings Programs may help pay Medicare Part B premiums, deductibles, coinsurance, or copays. Extra Help is more specifically tied to Medicare Part D prescription drug costs.
  • MSP Medicare Savings Program Medi Cal pays Part B premium
  • Medi-Cal Information
  • Medi-Cal Share of Cost
    • You can still deduct Part B Premiums when calculating how much you need to spend on health – dental premiums
  • Medi-Medi Medicare & Medi-Cal
  • Medicare Enrollment Information
  • Medicare Part D Prescription Drug Coverage

Part B vs. Part D Drug Confusion

• Some expensive medications may fall under Medicare Part B instead of Part D depending on how and where the medication is administered. This can become extremely confusing for beneficiaries trying to understand their costs.
• An example sometimes discussed involves infused antibiotics such as daptomycin. Depending on the circumstances, Medicare Part B, Part D, supplemental insurance, Medicare Advantage rules, or Medi-Cal coordination may all affect coverage differently.

Why This Page Matters

• At many Medicare agent training meetings, Extra Help and low-income prescription assistance programs are discussed frequently because they can dramatically reduce medication costs for qualifying beneficiaries.
• Unfortunately, many seniors do not know the program exists, assume they earn too much to qualify, become overwhelmed by the application process, ignore confusing Medicare notices, or do not understand the difference between Part B, Part D, Medi-Cal, Medicare Advantage, Medigap, and Extra Help.

Need Help?

If you have questions about Medicare prescription drug coverage, Medicare Advantage, Medigap, Medi-Cal coordination, Medi-Medi eligibility, or whether you may qualify for Extra Help, feel free to contact Steve Shorr Insurance.  [email protected]

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