Low-income Medicare recipients may qualify for additional coverage with their state’s Medicaid program. Extra Help can help reduce out-of-pocket costs for qualifying Medicare recipients in need of Medicare Part D prescription drug coverage.

Qualifying for Medicare-Medicaid Dual Eligibility

Medicaid is a federally funded program, but each state is in charge of administering the program for its qualifying residents. Due to changes in the cost of living in each state, eligibility for Medicaid can be different in each state. Eligibility rules can also change throughout the year.

Calling your state’s local Medicaid office is the only way to know for sure what the eligibility requirements are in your circumstances, but certain factors are easier to determine beforehand.

Medicaid eligibility criteria will typically consider the following:

  • Income. Both earned and unearned income is considered when an applicant applies for Medicaid services. There may be qualifying deductions subtracted from the total amount of income that can lower the measurable amount below any program limit.
  • Assets. Resources with cash value, such as savings and investment accounts or certain types of property may be measured against program limits. Some states may not have an asset limit for certain demographics.
  • Spend down. If an applicant’s income or resources exceed program limits, qualifying expenses may be subtracted from their measurable income or resources to bring them under their state’s program limits for eligibility.

Many qualifying Medicare beneficiaries are automatically notified if they are eligible for Extra Help in their state. This is often the case for Medicare recipients who receive retirement benefits and are no longer working. If you think you qualify for the Extra Help program but have not been notified of it before, you can call your local Medicaid office to discuss eligibility requirements.

You may qualify for Extra Help even if you already have creditable prescription drug coverage through another provider. In that case, you should carefully evaluate your options to determine which one will keep your out-of-pocket expenses as minimal as possible.

Benefits with the Medicare Part D Extra Help Program

Recipients who qualify for this low-income assistance can expect the following benefits:

  • Monthly premium payment. Part D plans are carried by private insurers and the monthly premium can be different depending on the level of coverage the plan offers. You state may set a limit on the portion of the premium Extra Help pays.
  • Lower drug costs. Extra Help sets a limit to your out-of-pocket costs for each prescription copay or coinsurance amount. If your plan’s copay is less than the one Extra Help offers, you pay what your plan charges.
  • No late enrollment penalty. Medicare recipients who delay enrollment in a Part D plan when they first become eligible may be charged a penalty for late enrollment. Extra Help eliminates this penalty.
  • Separate Special Enrollment Period (SEP). Each year, Fall Open Enrollment allows Medicare recipients to change which plan they use for Part D coverage. Extra Help recipients get a second one-yearly opportunity to switch plans outside of the Open Enrollment period.

Extra Help is not a prescription drug plan separate from Part D, it is simply a way that Medicare-Medical dual-eligibles can receive extra assistance in paying for their Part D plan and any prescription medications they require.

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