How to Check Medicare Extra Help Eligibility for Your Client

Is your client eligible for the Medicare Extra Help program? You could play a huge role in getting them financial assistance with prescription drug coverage and medications. What are the income limits for Part D Extra Help, and are there Medicare Extra Help look-up tools?

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If you’ll be discussing prescription drug coverage during an appointment, it’s important that you verify whether your client qualifies for the Extra Help with Medicare. This federal program could mean the difference between your client having affordable access to important medications in their doctor’s treatment plan or not!

Note: If a client does not meet the Medicare Extra Help income limits, that does not automatically disqualify them from state assistance programs! The eligibility guidelines for these programs can differ, so be sure to check on a client’s eligibility for both types of assistance.

What Is the Medicare Extra Help Program?

The Extra Help program is a joint effort by the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA) to provide financial assistance to those who need it to pay for their Medicare prescription drug coverage and prescription drugs. This program is also called the “Medicare Low-Income Subsidy program.”

How does the LIS/Extra Help program work?

Enrollees in this program usually DO NOT have to pay:

• Premiums for their prescription drug coverage
• Deductibles for their prescription drug coverage (unless they only receive a partial subsidy instead of the full one)
• The Part D late enrollment penalty
• Full copays or coinsurance
• More than $4.90 for each generic drug
• More than $12.15 for the prescription drugs their plan covers

Once total drug costs reach $8,000, your client pays $0 for each covered drug. This out-of-pocket amount will be capped at $2,000 beginning in 2025.

If your client also gets full Medicaid coverage and are in the Qualified Medicare Beneficiary (QMB) program, they won’t pay more than $4.60 for each covered drug.

Program members also get a monthly Special Enrollment Period to join or switch Medicare Part D plans. Over the course of a year, someone on Medicare who is receiving Extra Help could potentially save about $5,100!

Who Automatically Qualifies for Extra Help for Medicare Part D?

Some people automatically receive the LIS, meaning they don’t need to complete the Extra Help application. Here are the individuals who should automatically receive Extra Help:

• Individuals who are eligible for both Medicare and Medicaid (dual-eligibles)
• People who receive Supplemental Security Income (SSI)
• Those who qualify for a Medicare Savings Program

Looking Up or Verifying Medicare Extra Help Status

It’s unlikely your clients will know, or recognize, if they qualify for or receive the LIS/Extra Help, unless they’ve applied for it, and even then, their status may have since changed. During appointments, agents should confirm whether their client qualifies for the LIS/Extra Help before enrolling them in a prescription drug plan. By doing this, you’ll be acting in your clients’ best interests, helping them to afford the medications they need and even save money on their prescriptions. What better way to show your clients that you’re the right agent to get the job done?

Extra Help/LIS Income Limits & Eligibility Requirements

To qualify for the LIS or Extra Help, an individual must:

• Have Medicare Part A and/or Part B
• Live in one of the 50 United States or the District of Columbia
• Have less than $34,360 (married) or $17,220 (single) total in savings, investments, and real estate net worth (exceptions may apply, limits may change from year to year)
• Have an annual income limited to $30,660 (married) or $22,590 (single).

Extra Help/LIS Look-Up Tools and Methods

You’re likely more technology savvy than your clients. It will likely be easier for you to just look up their LIS status for them, or with them, rather than trying to explain to your clients how to do it themselves and waiting for an answer. If you’re ready to verify a client’s LIS status, you can do this with CMS or the carrier, online or over the phone.

Five ways to verify a client’s Medicare Extra Help status:

1. Use an LIS look-up tool in a carrier’s portal (if the carrier has one).
2. Call the carrier and ask to confirm your client’s LIS eligibility.
3. Call 1-800-Medicare (1-800-633-4227) and ask to confirm your client’s LIS eligibility.
4. Have your client create and/or log in to their MyMedicare.gov account and check if they qualify for the LIS.
5. Ask your client to use the Find Out If You Qualify tool available on SSA.gov.

Note: These tools are available pre-enrollment to check a client’s eligibility prior to enrollment.

Will My Client Be Notified If Their Extra Help Status Changes?

If your client’s Extra Help status changes, they should receive a notification from CMS or the SSA via mail. The color of the notice will vary, depending on the purpose the notice serves.

Helping Your Client Apply for Extra Help with Medicare

Anyone who does not automatically get the LIS, should complete the Medicare Extra Help application if there’s a chance they are eligible for it. If you think your client may qualify for this program, you can help them apply for it via the Social Security Administration’s website. Clients can also call or visit their local Social Security office to apply. Individuals who need further assistance can contact their State Health Insurance Assistance Program (SHIP).

Did you know that CMS estimates three million Medicare beneficiaries aren’t enrolled in the government’s Medicare Extra Help program but could benefit from it? Don’t let your clients be a part of this statistic. Help them take advantage of the financial assistance they’re entitled to, but may not know about, starting today!

Editor’s Note: This post has been updated to include information relevant for 2024.