Extra Help and Medicare Savings Programs for Disability Recipients

If you get Social Security disability (SSDI or SSI) and you're on Medicare with a limited income, two programs can lower your health costs right now: Extra Help (which cuts what you pay for prescription drugs) and the Medicare Savings Programs (which can pay your Medicare Part B premium and, in the strongest version, cover your Medicare deductibles and copays). Both are underused, largely because people assume they earn or own too much to qualify. Many do qualify. The limits are often higher than people guess, and most of them change every year, so a "no" you assumed years ago may not be a "no" today.

Extra Help: lower costs for your Medicare drug plan

Extra Help is the common name for the Medicare Part D Low-Income Subsidy (LIS). If you qualify, it reduces or eliminates your Part D premium, eliminates your annual deductible, and caps what you pay per prescription at a small copay instead of the plan's regular cost-sharing.

One important change: beginning in 2024, the partial-subsidy tier was eliminated. Everyone who now qualifies for Extra Help receives the full subsidy. If you were turned down years ago, or were told you only qualified for partial help, it is worth applying again.

You do not need to already have a drug plan to apply, and you do not need an SSDI award to qualify - Extra Help is based on your income and resources, not on a disability finding. Two groups are enrolled automatically:

• SSI recipients who have Medicare are generally deemed eligible for Extra Help automatically, with no separate application.
• People who have both Medicare and Medicaid, or who are enrolled in a Medicare Savings Program (below), are also generally deemed eligible automatically.

Everyone else has to apply. You can apply online at ssa.gov, by phone, or at a Social Security office, using SSA's Application for Extra Help with Medicare Prescription Drug Plan Costs (Form SSA-1020). There is no cost to apply, and applying has no effect on your disability claim or your benefits.

A useful side effect: applying for Extra Help can trigger an MSP review

When you apply for Extra Help through Social Security, SSA sends your information to your state Medicaid agency, and federal law directs the state to treat that data as the start of a Medicare Savings Program review unless you decline. It is not a substitute for a state application everywhere, but it is a real head start - and one more reason to apply for Extra Help even if you are unsure you will qualify.

Medicare Savings Programs: help with your Part B premium (and more)

Medicare Savings Programs (MSPs) are run by your state Medicaid agency, not by Social Security. That is why you apply in a different place and why the eligibility rules differ from Social Security's own programs. There are four, layered roughly by income from lowest to highest:

• QMB (Qualified Medicare Beneficiary) - the most generous. QMB pays your Medicare Part A premium if you owe one, your Part B premium, and your Medicare deductibles, coinsurance, and copays. If you are in QMB, federal law bars Medicare providers and suppliers - doctors, hospitals, pharmacies - from billing you for that cost-sharing, even when the state's payment to them is less than the Medicare rate. That protection applies whether you have Original Medicare or a Medicare Advantage plan. If a provider bills you anyway, that is improper balance billing, and you can report it to 1-800-MEDICARE or your state Medicaid agency.
• SLMB (Specified Low-Income Medicare Beneficiary) - pays your Part B premium.
• QI (Qualifying Individual) - also pays your Part B premium, for people with income slightly above the SLMB ceiling. QI is funded from a limited annual state allotment and is generally awarded on a first-come, first-served basis, so applying early in the year helps. You cannot receive QI and Medicaid at the same time.
• QDWI (Qualified Disabled and Working Individual) - a narrow program for certain people under 65 who lost premium-free Part A because they returned to work but still have a disabling impairment. QDWI helps pay the Part A premium.

All four are worth a look if you are disabled and on Medicare - whether your Medicare came from turning 65, from the 24-month Medicare waiting period that follows SSDI entitlement, or from one of the exceptions to that wait: people approved on the basis of ALS (amyotrophic lateral sclerosis) get Medicare without the 24-month wait, and people with ESRD (end-stage renal disease requiring dialysis or a transplant) qualify under separate ESRD rules.

Who qualifies - in general terms

Both programs look at your monthly income and your countable resources (money in the bank, stocks, and similar assets - typically not your home and not one vehicle). A few honest generalities, rather than numbers that would be stale within months:

• The limits are higher than most people assume. People with modest Social Security benefits, or SSDI plus a small pension, are often surprised to find they qualify for at least one of these programs.
• MSP income and resource limits vary by program and by state. QMB has the lowest income ceiling, SLMB is higher, and QI is higher still. Some states are more generous than the federal minimum - a number of states have dropped the resource test entirely - and Alaska and Hawaii use different federal poverty figures than the other states. There is no single national number that is accurate for everyone, which is why this article does not print one: your state Medicaid agency and medicare.gov post the current limits.
• Extra Help has its own federal income and resource test, which is not the same as SSI's test and not the same as your state's MSP test. You can qualify for one and not the other, or for both.
• Not everything counts. Certain income and resources are excluded (for example, part of your earnings is disregarded, and certain burial funds and, for Extra Help, the value of life insurance are not counted). Do not rule yourself out on a rule of thumb - the agency that takes your application, not your own estimate, decides whether you qualify.

What to do

1. Apply for Extra Help at ssa.gov, by phone at Social Security's national number, or at your local Social Security office - unless you already get SSI or Medicaid, in which case you are likely enrolled automatically. Check your Part D plan's materials or call 1-800-MEDICARE to confirm the subsidy is showing.
2. Apply for a Medicare Savings Program through your state Medicaid agency. In most states this is a separate application from Extra Help, even though applying for one prompts a look at the other. Medicare.gov lists your state's contact information.
3. Get free, unbiased help if the paperwork is confusing. Every state has a State Health Insurance Assistance Program (SHIP) - federally funded, free, and staffed by counselors who handle exactly these applications, with nothing to sell you. Medicare.gov can connect you to your state's SHIP.
4. If you are denied an MSP, get the reason in writing and ask about your appeal rights. States run their own appeal processes with their own deadlines, which are separate from Social Security's roughly 60-day disability appeal deadlines - do not assume the same clock applies. Read the notice carefully and act by the exact date it gives; missing that date can cost you the appeal.
5. Report changes. If your income, resources, household, or state of residence changes, tell Social Security (if you get SSI) and your state Medicaid agency, since eligibility for both Extra Help and an MSP can change with your circumstances. Reporting honestly and promptly is also how you avoid an overpayment you would later have to repay.

A word of caution

These are government programs, and there is never a fee to apply for either one. Be wary of anyone who calls or emails offering to "enroll" you in Extra Help or a Medicare Savings Program for a fee, who asks for your Medicare or Social Security number to "confirm eligibility," or who pressures you to switch drug or Medicare Advantage plans as a condition of "helping" you get these savings. Apply directly through ssa.gov, your state Medicaid agency, or a SHIP counselor - never through a cold call. (The same principle governs disability representation generally: a legitimate representative is paid out of approved past-due benefits with SSA's approval, not through an up-front fee, and nobody can lawfully guarantee you an approval.)

This article is general information, not legal or medical advice, and reading it does not create an attorney-client relationship. For help with your own situation, contact Social Security, your state Medicaid agency, Medicare, or your local State Health Insurance Assistance Program directly.