covered under one of the Medicare Savings Programs as a Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Individual (QI).
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.
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:
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].
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.
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; andSends SSA data to support requests for Part D premium withholding (or stops Part D premium withholding) from the Title II benefit.
Deeming is a CMS activity; SSA does not make these determinations and cannot address any appeals of deeming decisions.
Medicare beneficiaries are automatically deemed subsidy-eligible and should not apply for Extra Help if they: