If a beneficiary is not deemed eligible for Medicare Part D Extra Help, the beneficiary
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, if applicable, the Extra Help benefit level.
SSA Extra Help eligibility determinations that have a coverage start date:
-
1.
On or after January 1, 2024, will indicate one of the following results:
-
•
Full premium subsidy (the highest level of subsidy under the Medicare Part D Extra
Help Program) of the service area's benchmark base premium with no deductible and limited copayments.
-
•
Not eligible for subsidy.
NOTE 1: The Inflation Reduction Act (IRA) increases income limits for full subsidy from income
less than 135% of the Federal Poverty Level (FPL) to income less than 150% of the
FPL for Extra Help applications with coverage start dates on or after January 1, 2024.
To locate the coverage start date field in MAPS, see MS 03301.08C [11-D].
-
2.
Before January 1, 2024, will indicate one of the following results:
-
•
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
and copayments;
-
•
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 3: 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
of information.
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
process.
An SSA subsidy determination award (coverage start date) is generally effective:
-
•
the month the beneficiary applies for Extra Help if already enrolled with a PDP/MA-PD,
or
-
•
the month after the month of enrollment with the PDP/MA-PD.
EXCEPTION: A subsidy determination cannot have a coverage start date 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 subsidy eligibility. SSA redetermines eligibility for all Extra Help initial determinations made by SSA.
More information about Extra Help redeterminations is available in HI 03050.020.For information on the Extra Help appeal process, see HI 03040.001.