Effective Dates: 04/09/2024 - Present Previous | Next

TN 25 (04-24)

HI 03001.005 Medicare Part D Extra Help (Low-Income Subsidy or LIS)

A. Extra Help and deemed subsidy eligible

The Medicare Part D Extra Help program helps Medicare beneficiaries with limited income and resources pay for prescription drug coverage. Eligible beneficiaries receive subsidized premiums, deductibles, and co-payments. Subsidized premiums are paid to the prescription drug plan (PDP) or Medicare Advantage prescription drug plan (MA-PD) by the Centers for Medicare and Medicaid Services (CMS) and are based on the service area’s regional benchmark premiums. Individuals who are eligible for Extra Help with a full premium subsidy who choose to participate in a more expensive plan, are responsible for the difference between the benchmark premium and the premium of the plan they choose.

Certain beneficiaries are automatically deemed subsidy-eligible and should not complete an application for Extra Help. These beneficiaries have Medicare Parts A or B, or both, and are:

 

  • •

    already entitled to Supplemental Security Income (SSI),

  • •

    eligible for full Medicaid coverage, or

  • •

    covered under one of the Medicare Savings Programs as a Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Individual (QI).

NOTE: 

Qualified Disabled Working Individuals (QDWI) are not deemed eligible for Extra Help. For more information about these groups, see HI 00815.023 and HI 00815.025.

B. SSA and Extra Help

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. 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. 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.

 

NOTE: 

More information about Extra Help redeterminations is available in HI 03050.020.For information on the Extra Help appeal process, see HI 03040.001.

 

C. CMS, deemed subsidy eligibles, and Extra Help eligibles

For individuals deemed subsidy-eligible and beneficiaries filing an application for Extra Help, CMS:

 

  • •

    Determines if an individual is deemed eligible for the low-income subsidy based on monthly data from State Medicaid agencies and SSA’s records of SSI participation;

  • •

    Automatically enrolls (auto-enrolls) deemed-eligible beneficiaries who have not yet enrolled with a PDP or MA-PD. CMS also assists in the enrollment of beneficiaries who are approved for Extra Help but have not enrolled in a PDP or MA-PD under a process called facilitated enrollment. (See HI 03001.010);

  • •

    Sends notices to beneficiaries who lose their deemed status and provides an SSA application for Extra Help (Beneficiaries lose deemed status the end of the calendar year of their notification of termination.);

  • •

    Determines the dollar value of Extra Help a beneficiary may receive from the percentage data provided by SSA;

  • •

    Notifies SSA of Medicare terminations; and

  • •

    Sends SSA data to support requests for Part D premium withholding (or stops Part D premium withholding) from the Title II benefit.

 

NOTE: 

Deeming is a CMS activity; SSA does not make these determinations and cannot address any appeals of deeming decisions.

D. Deemed eligibility and applying for Extra Help

Medicare beneficiaries are automatically deemed subsidy-eligible and should not apply for Extra Help if they:

 

  • •

    have Medicaid;

  • •

    enroll in a QMB, SLMB, or QI program; or

  • •

    receive SSI.

Almost all Medicare Part D Extra Help applications are taken and processed by SSA. A prescribed subsidy application filed with us includes the:

 

  • •

    SSA-1020-OCR, scannable paper version (HI 03010.035B.1.) in English and Spanish;

  • •

    i1020, online version on SSA’s Internet website (HI 03010.035B.3.); or

  • •

    Intranet via the Medicare Application Processing System (MAPS) screens (MS 03205.000) completed by an SSA employee (HI 03010.010).

State Medicaid agencies may use the Extra Help application, which may be a paper SSA-1020-OCR or i1020. However, if the Medicaid agency chooses to use a non-SSA application, the agency must process the application, make the subsidy determination (and subsequent annual redeterminations or appeals), and share applicable data with CMS directly. CMS shares the appropriate data with SSA. This is very rare.

E. Beneficiary contacts 800#, field office (FO), or workload support unit (WSU)

The preferred method of filing for Medicare Part D Extra Help is through our online application, the i1020. Refer beneficiaries first to the online process.

1. 800# process

If a beneficiary calls and needs help with the Extra Help application or needs a form to file for Extra Help, 800# agents should follow Medicare Prescription Drug Subsidy eligibility and filing instructions (TC 24020.020).

2. FO and WSU process

If a beneficiary contacts the FO and requires assistance completing the Extra Help application or alleges non-receipt of a form and wants to file for Extra Help, follow the instructions in HI 03010.001 through HI 03010.040.

F. Questions about enrollment

People who file an application and establish eligibility for Extra Help may or may not be enrolled with a PDP or MA-PD plan. Some Extra Help beneficiaries who do not enroll with a PDP or an MA-PD are enrolled in a plan selected by CMS; however, they may choose not to be enrolled. For information about facilitated enrollment, see HI 03001.010.

Enrollment is generally effective the month after the enrollment request is filed with the PDP or MA-PD. For more information regarding specific enrollment periods and effective dates of coverage see, HI 03001.001F.

Beneficiaries with questions about enrolling or choosing a PDP or MA-PD should call 1-800-MEDICARE (1-800-633-4227). The Medicare TTY number is 1-877-486-2048. Refer beneficiaries to their State Health Insurance Counseling and Assistance Program (SHIP) for assistance in choosing a PDP or MA-PD. SHIP telephone contact information is located towards the end of the “Medicare & You ” handbook or may be accessed on the SHIP website by clicking the SHIP locator button and selecting the State .

G. Full and partial subsidies

An individual can qualify for a full or partial Medicare Part D subsidy depending on the subsidy coverage start date, income, resources (including those of the living-with spouse), and household size. Total resources are compared to resource limits for individuals and couples.

Income is based on the Federal Poverty Level (FPL), which considers the number of persons in the household. To determine household size, a relative is considered in the same household as the beneficiary if the relative (by blood, marriage, or adoption) receives at least one-half support from the beneficiary or the living-with spouse. For more information about income and the FPL, see HI 03020.055 and HI 03001.020C.

NOTE 1: 

When discussing Extra Help, it is important to remember that a person who receives a 100% premium subsidy is not necessarily “full subsidy eligible.” A person with income (including a living-with spouse’s income) below 150% of the FPL who enrolls in a Part D plan that has a premium that exceeds the CMS set "benchmark" amount for the individual's area, may be responsible for paying a portion of the plan’s premium.

Effective January 1, 2024, The Inflation Reduction Act (IRA):

 

  • •

    Increases the income limits for full subsidy from income less than 135% of the Federal Poverty Level (FPL) to income less than 150% of the FPL;

  • •

    Increases the resource limits for full subsidy to the highest single and married resource limits, eliminates the low single and married resource limits; and

  • •

    Ends Extra Help partial subsidy eligibility and eliminates the partial subsidy. For a more detailed explanation of resource limits or to view resource limits before 2024, see HI 03030.025.

NOTE 2: Individuals awarded partial subsidy before January 1, 2024, who remain eligible for Extra Help in 2024, automatically change from partial subsidy eligible to full subsidy eligible starting January 1, 2024.

 

2024 resources standards chart for individuals/couples

 

 

 
​

With Burial Exclusion

Without Burial Exclusion

Resource Levels

$17,220/$34,360

$15,720/$31,360

NOTE: 

For purposes of determining countable resources for Medicare Part D Extra Help subsidy eligibility, $1,500 is excluded from an applicant’s countable resources if the applicant expects to use some resources to pay funeral or burial expenses. For a married couple who live together, we exclude up to $3,000 ($1,500 for each member who expects to use some resources to pay funeral or burial expenses). For more information about resource exclusions see HI 03030.020.

The charts below explain the basic Part D benefit and the Extra Help available in 2024 and 2023 for each subsidy level and deemed eligibles. All resource limits shown include the $1,500 per person burial exclusion.

 

1. Part D coverage for 2024

  1. a. 

    For individuals/couples with income at 150% FPL or ABOVE, or with countable resources GREATER than $17,220/$,34,360 or both (basic benefit)

     

     

    If income is

    150% FPL or above

    And resources are

    NONE to greater than resource limit for the year

    The deductible is

    No more than $545

     

    After deductible, beneficiary pays 25% in out-of-pocket drug cost up to $5,030.

    The copayment is

    Varies. Each PDP and MA-PD plan places drugs into different levels called “tiers”. Drugs in each tier have a different cost.

    The coverage gap is

    Beneficiaries pay 25% of out-of-pocket costs for generic and brand-name drugs between $5,030 and $8,000 (usually representing the beneficiary + manufacturer + plan total gross covered drug costs of $11,477.39).

    Catastrophic coverage applies

    After $8,000 in total out-of-pocket drug costs are paid by the beneficiary, the beneficiary pays $0 for the rest of the calendar year.

  2. b. 

    For individuals/couples NOT eligible for SSI, Medicaid, or Medicare Savings Programs with income LESS than 150% FPL (Low-Income Subsidy)

     

     

    If income is

    Less than 150% FPL

    And resources are

    $17,220 or less for individuals,

    $34,360 or less for couples

    The deductible is

    NONE

    The copayment will be

    Beneficiaries pay no more than $4.50 (for generic) or $11.20 (for name brand) out-of-pocket drug costs up to $8,000.

    The coverage gap is

    Covered – If the beneficiary is receiving Extra Help there is no coverage gap.

     

    Co-insurance levels of $4.50 (for generic) and $11.20 (for name brand) drug costs will continue to apply.

    Catastrophic coverage will apply

    After $8,000 in out-of-pocket drug costs paid by beneficiary, the beneficiary pays $0 for the rest of the calendar year. .

  3. c. 

    Individuals deemed eligible for Extra Help

     

    Full Subsidy

     

    Full Benefit Dual Eligible (FBDE) (eligible for both Medicare & Medicaid)

    Non-institutionalized beneficiaries

     

    Full Subsidy

     

    FBDE

     

    Non-institutionalized beneficiaries

     

    Or

     

    Full subsidy FBDE beneficiaries who are institutionalized (or would be institutionalized if they were not receiving home and community-based services)

    If income is

    Above 100% FPL

    Up to and including 100% FPL and full Medicaid eligible

    And resources are

    N/A - Deemed eligible

    N/A - Deemed eligible

    The deductible is

    NONE

    NONE

    The copayment is

    $4.50 (for generic) and

    $11.20 (for name brand) medications

    $1.55 (for generic) and

    $4.60 (for name brand) medication

    The coverage gap is

    N/A

     

    Copayments remain at $4.50 (for generic) and $11.50 (for name brand) drug cost levels

    N/A

     

    Copayments remain at $4.50 (for generic) and $11.50 (for name brand) drug cost levels

     

    Catastrophic coverage is

    $0

    $0

2. Part D coverage for 2023

2023 resources standards chart for individuals/couples

 

 

 
​

With Burial Exclusion

Without Burial Exclusion

Lower Resource Levels

$10,590/$16,630

$9,090/$13,630

Higher Resource Levels

$16,660/$33,240

$15,160/$30,240
  1. a. 

    For individuals/couples at 150% FPL or ABOVE, or with countable resources GREATER than $16,660/$33,240 or both (basic benefit)

     

     

    If income is

    150% FPL or above

    And resources are

    NONE to greater than resource limit for the year

    The deductible is

    $505

    The copayment is

    After deductible, 25% up to $4,660 in out-of-pocket drug cost

    The coverage gap is

    The beneficiary is responsible for 25% of out-of-pocket costs of brand-name drugs and generic drugs between $4,660 and $10,516.25.

    Catastrophic coverage applies

    After $7,400 in total out-of-pocket covered drug costs are paid by the beneficiary (usually representing $10,516.25 in covered drugs), the beneficiary pays the greater of (i) 5 percent of the drug cost or (ii) $4.15 for generic or preferred medications or $10.35 for other covered medications.

  2. b. 

    For individuals/couples NOT eligible for Medicaid, BUT between 136% and 149% of FPL (Low-Income Subsidy)

     

     

    If income is

    Between 136% and 149% FPL

    • •

      25% premium subsidy from 146-149%

    • •

      50% premium subsidy from 141-145%

    • •

      75% premium subsidy from 136-140%

    And resources are

    $16,660 or less for individuals,

    $33,240 or less for couples

    The deductible is

    $104

    The copayment will be

    After deductible, 15% up to $7,400 in out-of-pocket drug costs

    The coverage gap is

    Covered – If the beneficiary is receiving Extra Help there is no coverage gap

    Catastrophic coverage will apply

    After $7,400 in out-of-pocket covered drug costs paid by beneficiary, the beneficiary pays the greater of (i) 5 percent of the drug cost or (ii) $4.15 for generic or preferred medications or $10.35 for other covered medications.

  3. c. 

    For individuals/couples NOT eligible for Medicaid, BUT less than or equal to 135% of FPL (Low Income Subsidy)

     

     

     

    If income is

    Less than or equal to 135% FPL with higher resources level

    Less than or equal to 135% FPL with lower resources level

    And resources are

    Greater than $10,590 but do not exceed $16,660 for individuals

    Greater than $16,630 but do not exceed $33,240 for couples

    $10,590 for individuals,

    $16,630 for couples

    The deductible is

    $104

    NONE

    The copayment will be

    After deductible, 15% up to $7,400 in out-of-pocket drug costs

    $4.15 for generic/preferred and

    $10.35 for other medications

    The coverage gap is

    Covered – If the beneficiary is receiving Extra Help there is no coverage gap

    N/A

    Catastrophic coverage will apply

    After $7,400 in out-of-pocket covered drug costs are paid by the beneficiary, the beneficiary pays the greater of (i) 5 percent of the drug cost or (ii) $4.15 for generic or preferred medications or $10.35 for other covered medications.

    N/A
  4. d. 

    For non-institutionalized individuals deemed eligible for Extra Help

     

     

     

    If income is

    Over 100% FPL

    Up to and including 100% FPL and full Medicaid eligible

    And resources are

    Limited by the rules of the qualifying program

    Limited by the rules of the qualifying program

    The deductible is

    NONE

    NONE

    The copayment is

    $4.15 for generic/preferred and

    $10.35 for other covered medications

    $1.45 for generic/preferred and

    $4.30 for other covered medication

    The coverage gap is

    N/A

    N/A

    Catastrophic coverage is

    N/A

    N/A

H. References

  • •

    HI 00815.023 Medicare Savings Programs Income Limits

  • •

    HI 00815.025 SSA Outreach to Low-Income Medicare Beneficiaries – Extra Help and Medicare Savings Programs

  • •

    HI 03001.001F Description of the Medicare Part D Prescription Drug Program

  • •

    HI 03001.010 Facilitated Enrollment and Special Enrollment Period for Individuals Eligible for Extra Help (Low Income Subsidy)

  • •

    HI 03001.020 Eligibility for Extra Help (Prescription Drug Low-Income Subsidy)

  • •

    HI 03010.010 Filing Applications

  • •

    HI 03030.020 Resource Exclusions

  • •

    HI 03010.035B.1. General Information about the Subsidy Application

  • •

    HI 03010.039 Exception Processing

  • •

    HI 03020.055 Income Limits for Subsidy Eligibility

  • •

    HI 03030.025 Resource Limits for Subsidy Eligibility

  • •

    HI 03035.005 Verification Policy within the Medicare Application Processing System (MAPS);

  • •

    HI 03035.006 Verification and Documentation Process for Medicare Application Processing System (MAPS);

  • •

    HI 03035.007 Verification and Documentation Instructions for Internal Revenue Service (IRS) data within the Medicare Application Processing System (MAPS);

  • •

    HI 03035.008 Chart of IRS Transaction Types Used for Verification

  • •

    HI 03040.001 Overview of Appeal Process for Medicare Part D Subsidy Determination

  • •

    HI 03050.020 Redetermination of Eligibility for Medicare Part D Extra Help (Low-Income Subsidy)

  • •

    MS 03205.001 through MS 03205.013 MAPS Application Screens

  • •

    TC 24020.020 Medicare Prescription Drug Subsidy Eligibility and Filing

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603001005
HI 03001.005 - Medicare Part D Extra Help (Low-Income Subsidy or LIS) - 04/09/2024
Batch run: 04/09/2024
Rev:04/09/2024