Your mom takes seven medicines, and every January her drug plan costs jump again. She's started cutting pills in half to make them last. Her pharmacist mentions a program called Extra Help, but your mom says she probably makes too much. You want to know whether it's worth applying and how to do it.
This guide uses Medicare.gov, the Social Security Administration and federal Part D regulations. We don't list income and resource limits or copay amounts, because they change every year. Medicare.gov publishes the current numbers. A free State Health Insurance Assistance Program (SHIP) counselor can help you apply3.
What Extra Help is
Extra Help is a Medicare program that helps people with limited income and resources pay for Medicare drug coverage (Part D), including premiums, deductibles, coinsurance and other costs1. It's sometimes called the Part D low-income subsidy. If your parent is also deciding how to fill gaps in Medicare, see Medigap vs. Medicare Advantage. Federal rules set eligibility using income compared with the federal poverty level and resources compared with set thresholds4.
For many people, Extra Help means a much lower or no plan premium, no deductible, and small set copays for generic and brand-name drugs, with costs dropping further once yearly drug spending reaches the out-of-pocket limit1. Medicare.gov lists the current amounts. People who get Extra Help also don't pay a Part D late enrollment penalty1.
Extra Help isn't available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands or American Samoa, though those areas have other programs1. Extra Help also removes the Part D late penalty.
Who gets Extra Help automatically
Your parent gets Extra Help automatically if they get any of these1:
- Full-benefit Medicaid coverage. Including a parent whose nursing home care is covered by Medicaid.
- Help from the state paying Part B premiums. That is, a Medicare Savings Program. See Medicare Savings Programs.
- Supplemental Security Income (SSI). Monthly SSI payments from Social Security.
People who qualify automatically get a notice in the mail explaining what they'll pay and, if they don't already have one, their new Medicare drug plan1. If your parent fits one of these groups and hasn't seen a notice, call Medicare or a SHIP counselor to check. Extra Help also lets your parent change drug plans at other times of year, but the fall window is still a good time to review; see our Medicare Open Enrollment guide.
Who should apply
If your parent doesn't qualify automatically, they can apply. In most cases, they must have income and resources below set limits, which may go up each year, and the limits are higher for married couples1. Medicare.gov lists the current limits and what counts toward them.
Many families assume their parent earns too much. The income limit is set above the federal poverty level4, so a parent living on a modest Social Security check and a small pension may well qualify. Resources generally include things like bank accounts, stocks and retirement accounts; ask Social Security or a SHIP counselor what counts in your parent's case. If you're unsure, apply. The application itself tells you the answer.
Documents to gather
Social Security suggests gathering these for your parent and their spouse before applying2:
- Bank statements and tax returns. Recent statements for every account.
- IRA or 401(k) balances. The most recent account statements.
- Statements for pensions, VA benefits, annuities and Railroad Retirement benefits. Award letters or recent payment statements.
Having these in front of you makes the online application faster and reduces follow-up requests from Social Security.
How to apply
- Apply online with Social Security. Your parent can apply any time, before or after enrolling in Part D2.
- Or call for an appointment. Social Security offers phone appointments in English, Spanish and other languages2.
- Decide about the MSP application. Social Security sends the information to the state to start a Medicare Savings Program application unless your parent says not to1. In most cases, let it go through.
- Get free help. A SHIP counselor can help with the application13.
- Watch for the decision. Keep the letter with your parent's Medicare papers.
If someone else is filling out the application, they should have your parent's permission or legal authority. See power of attorney for an elderly parent.
What happens after approval
If your parent qualifies and doesn't have a drug plan, Medicare automatically enrolls them in one so they get the savings. They'll get a notice about the new plan and can pick a different plan if they want1. Choosing a plan that covers all their medicines and uses their pharmacy matters, so compare plans with a SHIP counselor or on Medicare.gov.
Extra Help lasts for the rest of the calendar year, even if income changes mid-year. If your parent still meets the limits the next year, they keep getting Extra Help. Medicare mails a notice only if they no longer qualify or are being moved to a different plan; if no notice comes, they keep Extra Help and the same plan1.
Extra Help and Medicare Savings Programs
Extra Help and Medicare Savings Programs are partners. Anyone in an MSP that pays Part B premiums gets Extra Help automatically1. And an Extra Help application can start an MSP application with the state1. MSPs can lower Part B premiums and, for QMB members, Medicare deductibles and copays5. For a parent on a tight budget, the two together can add up to real monthly savings. See Medicare Savings Programs.
Choosing a drug plan with Extra Help
Extra Help lowers costs, but the plan still matters. Each Part D plan has its own list of covered drugs, pharmacy network and rules such as prior authorization. If Medicare enrolls your parent in a plan automatically, it's chosen to keep costs low, not necessarily to cover every medicine they take1. Your parent can choose a different plan1.
To compare, list every prescription with its dose, then use the Medicare.gov plan finder or ask a SHIP counselor to run the comparison3. Check that the plan includes your parent's usual pharmacy, or a mail-order option they're comfortable with. Look closely at any drug that needs prior approval or has quantity limits. Do this review every fall, since plans can change their drug lists and pharmacies from one year to the next.
Married couples and life changes
For married couples, Social Security asks about both spouses' income and resources, and the limits are higher for a couple12. If one spouse dies, moves into a nursing home or has a big change in income, the other spouse's eligibility may change too. Report changes to Social Security, and ask whether your parent should reapply.
Extra Help continues through December 31 even if income changes mid-year1. If your parent's situation improves, they won't lose help suddenly. If it gets worse, such as savings running low after paying for care, it may be worth applying again even if they were denied before.
Talking with your parent about it
Some older adults feel uncomfortable applying for help, or worry that it's charity. It can help to explain that Extra Help is part of Medicare, a benefit set up for people with limited income, and that applying is private and free. Offer to sit with your parent while they apply, or to gather the documents for them. If memory problems make paperwork hard, gently suggest that a trusted person be given authority to help with forms. See when an elderly parent refuses help.
If your parent lives in senior living
Extra Help works the same way wherever your parent lives. If their nursing home care is covered by full Medicaid, they get Extra Help automatically1. In assisted living, your parent's drug plan still applies, and the community's pharmacy may or may not be in the plan's network. Ask the community which pharmacies it works with before choosing a plan, and tell the staff about any change in coverage. If your parent's savings are being spent down on care, check eligibility again, because falling resources can make them newly eligible. See how to pay for assisted living.
Tips for helping a parent with drug costs
- Make a full medication list. Include doses, prescribers and pharmacy. It helps with plan comparisons and safety. See medication management.
- Review the drug plan every fall. Plans change formularies and costs from year to year.
- Ask about generics. A doctor or pharmacist can say whether a lower-cost option works.
- Don't let your parent ration pills. Skipping or splitting doses can be dangerous. Tell the doctor about cost worries.
- Keep all notices. Medicare and Social Security letters explain what your parent pays.
If your parent manages money with help, see managing an elderly parent's finances.
Common mistakes
- Assuming income is too high. The limit sits above the poverty level4. Apply and find out.
- Ignoring the automatic plan. Your parent can switch to a plan that fits their drugs better1.
- Opting out of the MSP application. It could lower Medicare premiums too1.
- Not applying because of a late penalty. Extra Help removes the Part D late penalty1.
- Missing the documents. Gather statements first2.
If your parent is denied and you think the decision is wrong, the letter explains how to appeal. A SHIP counselor can help3.
An example
Walter, 80, lives on Social Security and a small pension and has some savings. He doesn't get Medicaid, so his daughter helps him apply online for Extra Help after gathering his bank statements, pension letter and tax return2. He qualifies. His drug plan premium and deductible drop, and his copays become small set amounts1. Because he didn't opt out, Social Security also sends his information to the state, which approves him for a Medicare Savings Program15.
This is an illustration. Your parent's result depends on their income, resources and state.
Getting help
Start with Social Security for the application2 and a SHIP counselor for free, unbiased advice on plans3. For broader help with health costs, see how to apply for Medicaid for an elderly parent.
