Skip Navigation HRSA - U.S Department of Health and Human Services, Health Resources and Service Administration HHS
Home
Questions
Order Publications
 
Grants Find Help Service Delivery Data Health Care Concerns About HRSA

Medicare Part D & Ryan White HIV/AIDS Program

 
PDF Medicare Part D & Ryan White HIV/AIDS Program
(PDF – 69 KB)

Low Income Subsidies: Getting Help With Costs

Extra help available to pay prescription drug costs under Medicare.
Individuals with limited income and resources may qualify for extra help in paying Medicare prescription drug costs.

Some people automatically qualify for extra help and do not need to apply for it. They include the dually eligible (Medicare beneficiaries who also receive Medicaid); those covered by a Medicare Savings Program; and those who are covered by Supplemental Security Income (SSI). These individuals are required to make co-pays for each prescription drug until their total drug costs reach the catastrophic level for the year. Above this amount, they will not need to pay for their drugs at all.

Others with limited incomes and resources do not automatically qualify. They need to apply.

Eligibility criteria for those who apply for extra help.
Income and resource limits for qualifying change each year and include:

  • Annual income caps (which vary for those who are single versus married and living with the spouse). These amounts may be higher for those who: provide at least half of the support of other relatives living in your household, reside in Alaska and Hawaii, or are working. There are also income exclusions for the working blind and disabled.
  • Resource limits (which vary for those who are single versus married and living with your spouse). Examples of resources that are counted include real estate (other than primary residence); bank accounts, including checking, savings and certificates of deposit. Resources that are not counted include, for example, primary residence, personal vehicle(s), jewelry and home furnishings, household goods and personal possessions, and federal income tax refunds. Other things not counted as resources include designated amounts for burial expenses and life insurance policies owned by an individual with a combined face value as designated each year.

How to apply for extra help in paying for Part D costs.
Individuals can apply for extra help through the Social Security Administration (SSA) or Medicaid. An application must be completed—either an original application or one submitted online.

SSA sends people with certain incomes an application for extra help to pay for Medicare prescription drug coverage. Those who think they are eligible should fill out the application and return it in the postage paid envelope. Only original applications are accepted. Photocopies are not accepted. Another application can be requested and it will be mailed, but this can delay submission of the application. If the application does not arrive, one can be requested by calling SSA at 1-800-772-1213. Alternatively, individuals can apply online. SSA notifies applicants if they qualify for extra help.

Please note that SSA is just one place to go to apply for extra help with Medicare Part D costs. Those wishing to be screened for Medicaid and Medicare Savings programs, as well as for Part D extra help, should apply for all these programs at their State Medicaid office. SSA will not screen individuals for Medicaid or the Medicare Savings programs.

Co-payments and lowering them for those getting extra help.
Yes. For those covered by a Low Income Subsidy (LIS), clinicians can decrease the cost of co-pays by writing prescriptions for 60 or 90 days when appropriate, as opposed to just 30 days. This is because the same co-pay applies, regardless of the number of days covered by the prescription.

Part D impact on Medicare beneficiaries who qualify for Medicaid through "spend down" or medically needy programs.
Once a Medicare beneficiary becomes eligible for Medicaid (also known as "dually eligible"), the individual is deemed eligible for the low-income subsidy. This includes individuals who qualify for Medicaid through “spend down” or medically needy programs. Ryan White funds may not be used to cover an individual’s Medicaid “spend-down” costs.

Beneficiaries who are listed in data from states and SSA as recipients of Medicaid, a Medicare Saving Program (MSP) or Supplemental Security Income (SSI) will receive the subsidy. If they are again listed in data from states and SSA in the fall of each subsequent year, they will receive the subsidy for the following calendar year. If they cease to appear in data from the states or SSA as eligible for Medicaid, MSP, or SSI, they will not automatically receive the subsidy for the following calendar year and would have to apply in order to continue to qualify for the subsidy.