If a beneficiary is not deemed eligible for Medicare Part D Extra Help, he or she
may file an application with the State or SSA. However, SSA has primary responsibility
for taking applications for Extra Help and making determinations on those applications
in the 50 States and the District of Columbia. When a beneficiary applies for Extra
Help, SSA determines eligibility and the applicable percentage of Extra Help premiums.
An SSA eligibility determination indicates one of the following conditions:
Full premium subsidy of the service area’s benchmark base premium with no deductible
and limited copayments;
Full premium subsidy of the service area’s benchmark base premium with reduced deductibles
Partial premium subsidy of 75%, 50%, or 25% of the service area’s benchmark base premium
with reduced deductibles and copayments; or
Not eligible for a subsidy.
NOTE: For information on basic eligibility requirements for Extra Help, see HI 03001.020.
Extra Help application editing or exception issues (e.g., answers omitted or numbers
larger than the space provided on the form) are generally resolved in SSA’s Wilkes-Barre
Direct Operations Center (WBDOC).
Issues that are not editing or exception problems, but are data inconsistencies with
information available in SSA records and the information provided on the Extra Help
application, are sent to the appropriate field office (FO) or Workload Support Unit
(WSU) for resolution. If necessary, the FO or WSU contacts the applicant for verification
Detailed information regarding the exception and verification processes is found in
HI 03010.039 and HI 03035.005C.
SSA sends the subsidy determination notice to the beneficiary, including appeal procedures,
and transmits the application subsidy determination data to CMS. Starting January
1, 2010, unless a beneficiary declines, data used for the Extra Help determination
will be sent to the State to initiate the Medicare Savings Program (MSP) application
NOTE: For information on the Extra Help appeal process, see HI 03040.001.
An SSA subsidy determination of an allowance is generally effective:
the month the beneficiary applies for Extra Help if already enrolled with a PDP/MA-PD,
the month after the month of enrollment with the PDP/MA-PD.
A subsidy determination cannot be effective before Medicare entitlement begins or
before enrollment with a PDP/MA-PD becomes effective.
SSA periodically redetermines eligibility for Extra Help beneficiaries to determine
continued eligibility for a full or partial subsidy. SSA redetermines eligibility
for all Extra Help initial determinations made by SSA. More information about Extra
Help redeterminations is available in HI 03050.011.
Effective January 2010, unless the claimant objects, SSA will transmit Extra Help
determination data to the appropriate State Medicaid agency to begin the MSP application