TN 14 (10-09)

HI 03010.005 Interviewing For Medicare Part D Extra Help

A. Introduction

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.”

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:

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

  • Provides an updated Extra Help application that initiates an application for the Medicare Savings Programs (MSP), unless the beneficiary objects;

  • Provides general information on MSP; and

  • When requested, gives beneficiaries an MSP model application (available in English and 10 other languages) or refers them to SSA.gov where they can obtain the application online. States accept the applications from this site, even if they do not ordinarily use this form.

The model application is available in English and 10 other languages and is accessible in PDF format to the public online from the prescription help page at www.socialsecurity.gov/prescriptionhelp .

Applicants can scroll down on the right side, where the forms are located under “Additional Resources,” and click on “Medicare Savings Programs Model Application for Premium Assistance ,” or applicants can scroll down the middle and click on “The Official Government Site for People with Medicare.”

SSA employees can access the forms in multiple languages through the Public Affairs Resource Center (PARC) by selecting “Publications and Periodicals” and clicking on “Medicare Forms and Publications

NOTE: 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.

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 has Medicare, is eligible for Medicare, or who inquires about a prescription drug coverage plan or prescription drug coverage.

Field offices (FOs) should give copies of the worksheet, “What You Need to Complete the Application for Extra Help With Medicare Prescription Drug Plan Costs,” SSA Publication No. 05-10128, ICN 480068 to all claimants and beneficiaries who visit the FO and who want to:

  • 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

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

  • 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 http://mwww.ba.ssa.gov/pubs/10128.pdf

in English or http://mwww.ba.ssa.gov/espanol/10928.pdf in Spanish.

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

  • 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

  • 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:

  • Extra Help is for people who are eligible for Medicare benefits, see (HI 03001.010) for eligibility criteria, including enrollment periods.

  • Participation is voluntary.

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

  • Starting January 1, 2010, unless the claimant objects SSA sends identification and financial data used to make the Extra Help determination to the claimant’s state to start the MSP application process. The MSPs help with other Medicare cost-sharing, such as Medicare Part B premiums.

  • Statute establish income and resource limits to qualify for the subsidy, see (HI 03001.020) for eligibility criteria. Therefore, the claimant must provide information about his or her (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

  • 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 provider (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 Counseling and Assistance Program (SHIP). The telephone number of the appropriate SHIP is on the back of Medicare & You pamphlet, may also be located using http://www.medicare.gov/contacts/organization-search-criteria.aspx , or through SSA’s web site at http://www.socialsecurity.gov/prescriptionhelp .

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:

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

  • full Medicaid coverage, or

  • are in one of these Medicare Savings Programs: Qualified Medicare Beneficiaries (QMB) (SI 01715.005), Specified Low-Income Medicare Beneficiaries (SLMB) (SI 01715.005), or Qualifying Individuals (QI) (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 his or her eligibility. CMS also notifies him or her of the plan selection and provides instructions for changing plans or opting out of enrollment. See (HI 03001.001D) and (HI 03001.001F).

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, so long as Medicare entitlement continues, applications completed by those who are no longer deemed are effective January of the next year.

After the discussion outlined in subsection B. above, follow the temporary MIPPA interviewing guidelines, and take an Extra Help application, unless the beneficiary chooses not to file. Filing an Extra Help application:

  • permits SSA to make a formal determination of eligibility for Extra Help and whether or not the claimant should receive a full or partial subsidy;

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

  • permits the claimant to start the MSP application process (if application is filed January 2010 or later);

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

  • serves as a protective filing for SSI.

NOTE: Follow procedures in (HI 03010.020A.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 - 06/07/2016
Batch run: 06/07/2016
Rev:06/07/2016