Effective Dates: 02/01/2024 - Present Previous | Next

TN 48 (02-24)

HI 03010.005 Interviewing For Medicare Part D Extra Help

A. Background

SSA helps claimants and beneficiaries decide whether or not to apply for Extra Help.

NOTE: In discussions with the public, be sure to refer to Part D as “Medicare Prescription Drug Coverage” and refer to the subsidy as “Extra Help with prescription drug coverage.”

1. Medicare Improvements for Patients and Providers Act (MIPPA)

Public Law 110-275, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) expands SSA's responsibility to Extra Help (sometimes known as low-income subsidy (LIS) eligibles). Effective for Extra Help applications filed on or after January 1, 2010 and initial determinations effective on or after January 1, 2010, SSA:

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    No longer counts in-kind support and maintenance (ISM) as income or the cash surrender value (CSV) of life insurance policies as resources;

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    Sends data used for Extra Help determinations to state Medicaid agencies to initiate an application for the Medicare Savings Programs (MSPs) eligibility groups, unless the beneficiary declines to apply for the MSPs through the Extra Help application;

    NOTE: 

    The Medicare Savings Programs are Medicaid eligibility groups that cover Parts A and/or B premiums, and often, cost-sharing for individuals with limited incomes and resources.

  • •

    Provides general information on the MSPs, including how to get help applying through the State health insurance assistance program; and

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    When requested, gives beneficiaries their state MSP contact information or directs them to their state website.

    For help applying for the MSP through the State, direct beneficiaries to Beneficiary Resources | Medicaid.

    IMPORTANT: 

    The MIPPA changes to ISM and CSV of life insurance are only for Extra Help. The changes do not affect countable income or resources for any other program.

2. Inflation Reduction Act (IRA)

Public Law 117-169, the Inflation Reduction Act of 2022 (IRA), section 11404 effective January 1, 2024:

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    Increases the income limit for full subsidy from 135 percent of the Federal Poverty Level (FPL) to income below 150 percent of the FPL;

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    Increases the resource limits for full subsidy to what had been the high single and married resource limits for the partial subsidy and eliminates the lower single and married resource limits;

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    Provides full subsidy to all Extra Help beneficiaries;

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    Ends Extra Help partial subsidy eligibility; and

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    Provides $0 cost sharing above the annual out of pocket maximum and for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).

    NOTE: 

    For information regarding low and high resource limits, see HI 03001.005.

B. Procedure for Extra Help interviewing

1. When to discuss the prescription drug subsidy

Information about Extra Help should be shared with each Title II or end stage renal disease (ESRD) beneficiary who:

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    has Medicare;

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    is eligible for Medicare; or

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    inquires about a prescription drug coverage plan or prescription drug coverage.

Field offices (FOs) should give copies of the worksheet, “Understanding the Extra Help With Your Medicare Prescription Drug Plan,” SSA Publication No. 05-10508, ICN 470112 to all claimants and beneficiaries who visit the FO and who want to:

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    file for the Extra Help with Medicare prescription drug coverage costs, including beneficiaries who have been notified they may no longer meet deemed status, see (HI 03010.010A); or

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    file for Title II benefits and are enrolled in, entitled to, or filing for Medicare; or

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    discuss a post-entitlement action (e.g., a Social Security or Medicare letter or a change of address) and are enrolled in or entitled to Medicare.

FOs may download the worksheet from https://www.ssa.gov/pubs/EN-05-10508.pdf in English.

NOTE: 

It is not necessary to recontact beneficiaries about Extra Help who:

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    file an iClaim application. Links to information about Medicare Part D and Extra Help are presented on the “Next Steps” page of the application;

or

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    become entitled to Medicare as a result of an appeal. SSA automatically sends an application if data indicates the beneficiary meets the income criteria.

2. What to discuss with the beneficiary

Explain that:

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    Extra Help is for people who are eligible for Medicare benefits, see (HI 03001.020) for eligibility criteria, and see (HI 03001.010) for information on enrollment periods.

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    Participation is voluntary.

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    Extra Help assists with Medicare prescription drug coverage or Medicare Advantage costs through subsidized premiums, deductibles, and co-payments.

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    Since January 1, 2010, unless the claimant opts out, SSA sends data used to make the Extra Help determination to the claimant’s state to initiate an MSP application. The MSPs help with other Medicare cost-sharing, such as Medicare Part B premiums.

  • •

    There are income and resource limits to qualify for the subsidy, see (HI 03001.020) for eligibility criteria. Therefore, the claimant must provide information about their (and the living-with spouse’s) income and resources on the application.

NOTE: Effective January 1, 2010, SSA no longer counts ISM or the CSV of life insurance to determine Extra Help (LIS) eligibility or the level of subsidy.

C. How a beneficiary gets Extra Help

Extra Help with prescription drug coverage involves a two-step process. Claimants must:

  • •

    apply for the subsidy; and

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    be enrolled in a Medicare prescription drug coverage plan or MA-PD.

The claimant may take either step first. However, claimants who are awarded a subsidy and are not already enrolled with a prescription drug plan (PDP) or Medicare Advantage prescription provider (MA-PD), are enrolled automatically by the Centers for Medicare & Medicaid Services (CMS). CMS notifies the claimant of the plan selection and provides instructions for changing plans or opting out of enrollment.

When members of the public ask questions about enrollment in a prescription drug coverage plan or choice of providers, refer them to 1-800-MEDICARE or their servicing State Health Insurance Assistance Program (SHIP). The telephone number of the appropriate SHIP is on the back of the CMS publication titled Medicare & You | Medicare. SHIP contact information is also available online at "Contact Medicare" webpage or at shiphelp.org.

D. Beneficiaries who are automatically eligible for Extra Help

Some beneficiaries are automatically eligible for Extra Help (i.e., deemed eligible). These beneficiaries have Medicare and coverage in:

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    Supplemental Security Income (SSI) benefits (including 1619(b)), or

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    Full-benefit Medicaid coverage, and/or

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    One of the primary MSP eligibility groups: Qualified Medicare Beneficiary (QMB) group (SI 01715.005), Specified Low-Income Medicare Beneficiary (SLMB) group (SI 01715.005), or Qualifying Individual (QI) group (HI 00815.025).

    NOTE: Qualified Disabled Working Individuals (QDWI) are NOT deemed for Extra Help. See (HI 00815.023) and (HI 00815.025) for more information about this group.

Deemed eligibles should not file an Extra Help application. CMS notifies deemed eligibles of their eligibility. CMS also notifies them of the plan selection and provides instructions for changing plans or opting out of enrollment. See (HI 03001.001F.4) and (HI 03001.001J).

E. Title II or Title XVI issues

Take the appropriate action to resolve any issues that arise during the interview relating to other program benefits, (e.g., representative payee development appears to be warranted or a disabled insurance benefit (DIB) beneficiary reports workers’ compensation benefits or earnings that are not reflected on the record).

F. After the initial discussion

Each year, beneficiaries who are notified by CMS of loss of deemed status receive a copy of the Extra Help application to complete. SSA may receive applications from those who are no longer deemed eligible as early as September. Since deemed eligibility lasts throughout the current year, applications completed by those who loose deemed status are effective January 1 of the next year.

After the discussion outlined in subsection B. above, take an Extra Help application, unless the beneficiary chooses not to file. Filing an Extra Help application:

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    permits SSA to make a formal determination of eligibility for Extra Help and whether the claimant should receive a subsidy;

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    assures that the claimant can receive the Extra Help for any months that they are eligible and enrolled in a Medicare Part D or MA- PD plan;

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    permits the claimant to start the MSP application process;

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    gives appeal rights if the claimant disagrees with the determination; and

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    serves as a protective filing for Supplemental Security Income (SSI).

NOTE: 

Effective January 1, 2024, all Extra Help beneficiaries receive full subsidy. A partial subsidy determination can only be made on an Extra Help case that has a coverage start date before January 1, 2024. To locate the coverage state date field in MAPS, see MS 03301.008C. [11-D]. For information about MAPS determination dates, see MS 03206.021.

Follow procedures in HI 03010.020B.2. when a Title II claimant is potentially eligible for the subsidy.

G. References

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603010005
HI 03010.005 - Interviewing For Medicare Part D Extra Help - 02/01/2024
Batch run: 12/18/2024
Rev:02/01/2024