MAJOR LOW INCOME PROGRAMS 

DISCLAIMER: This information is NOT exhaustive.  Acceptance into any drug discount program cannot be guaranteed until a decision is made by the organization or agency running it.  However, general guidelines, like the ones below, can be very helpful when taken in context.  

Extra Help With Medicare Prescription Drug Plan Costs

Also known as 'Extra Help", it is not run by Medicare itself, although the benefits (lower drug costs) work through the Medicare drug plan you have.  That is worth noting because you have to enroll in this program through Social Security on SSA.gov or ordering a paper application by calling Social Security at 800-772-1213.  Again, it doesn't make a difference what Medicare drug plan you have or what insurance company you bought it from, you get the benefits all the same.  For example, if I live in Hawaii I get the same lowered costs (deductibles, copays, & premiums reduction) as is if I live in Texas with an entirely different insurance company.  And the same is true if I get my drug coverage through a Medicare Advantage plan.

 

INCOME & ASSET LIMITS: The income limit to qualify is 150% of federal poverty level (FPL) but Social Security will count your whole family income.  Also, you can't have too many assets not including your primary residence home, one vehicle, and basic personal belongings like furniture and such (valuables like expensive jewelry should be disclosed.  Income and asset limits almost always adjust slightly upward for inflation every year.  For 2021, the threshold that you can't go over are a little over $14,500 for single and $29,000 for couples.  If you have dependents, then asset and income limits go up.  

 

Interestingly, not all taxable income is counted the same.  Income from Social Security, pension or retirement, investments, mineral leases, home rentals, & most other income is counted dollar for dollar.  However, any kind of wages, meaning your working and paying payroll taxes, is only counted as a little less than half.  That doesn't mean they take money from you, just that the wages you earn don't fully count against your income limit of 150% FPL.  For example, if you get monthly income of $1000 in Social Security and approximately $1200 from your job, your total will not add up to $2200 since your wages are not fully counted against you.  The only way to know for sure if you qualify is to turn in an application and wait for a decision.  However, we can estimate your chances of qualifying and advise you if it is worth applying.  Once you know your exact income from all sources, the application only takes about 10 minutes or even less in simple cases.

We've seem many people who make slightly too much get Extra Help, and they are always seem to be people who get or once got Social Security Disability Income (SSDI).  Because of this, we have generally advised people who make slightly too much and are on SSDI to apply anyways, knowing the odds are against them.  It seems like that is smart, even if it is not for sure that you qualify.

 

TIMING: It takes generally 2 to 6 weeks to get approved or denied which will come in a letter from Social Security, but I have seen it shorter and longer many times.  You can apply anytime of the year and the start date is supposed to be retroactive the the beginning of the month in which you applied.  Many people want to apply before their Medicare starts so they can get the savings right away when Medicare starts.  Social Security allows applications up to 90 days before Medicare starts, but I have seen them say it was too early when people applied less than 90 days (we have only seen this a couple of times).  If we have any doubt about if an application has been unreasonably denied or lost by Social Security, we recommend doing a second application.  In our 10+ years experience, we've noticed many times when people have been approved on their second application after being denied on their first with no change whatsoever on their second application.

BENEFITS: It's worth repeating, all the benefits of this work through whatever drug plan you happen to have, regardless of the state or local county you live in or the insurance carrier you use or the specific plan you have or if you change plans.  That is both interesting and easy to miss.  So if I have an $80 drug plan with no deductible or a $20 plan with a deductible, I still get the same benefits from Extra Help.  Those benfits are:

      * Reduced Copays: varies depending on level of extra help awarded

     * Reduced or Eliminated Deductible: varies depending on level of extra help awarded

     * Reduced Premium: varies depending on level of extra help awarded

     * Ability to use an SEP to change your drug plan anytime Jan 1 thru Sept 30:

     * Elimination of the coverage gap, otherwise known as the donut hole:

     * Elimination of the Late Enrollment Penalty for Prescriptions (LEP):

     * Get 90 day supplies of meds for the same price as 30 day supplies:

     NOTE: Extra Help does NOT change the formulary (list of covered drugs) whatsoever.  Therefore, if          you take a prescription that is not covered, Extra Help will NOT reduce the copay for it.  There may          be other ways to get it covered or assistance that you can try, but the Extra Help in itself will do                nothing to cover prescriptions that are not listed on a formulary.

 

4 LEVELS OF EXTRA HELP: Depending on your exact income from all sources, Social Security will grant you one of four levels of extra help that dictates your copays, deductible, and premium reduction.  You have no control of what level you get other than your income.  There is no separate application to get one level over another.  Your granted level can very well change from year to year even if your income is generally or exactly the same.  There are two numbers that apply; a percentage which tells you what premium reduction you get and level (1 thru 4) which dictates the copay and deductible.

     Premium Reduction: 100%, 75%, 50%, 25% of a set amount that Social Security determines (generally       $20 to $25 per monthly premium).  However, each insurance carrier has the freedom to accept all or         none of the premium reduction.  They can even apply the reduction to each of their plans differently.       The bottom line here is that if you pick the right plan, and we know which ones, then you are going         to get a premium reduction.  Most people who have a 100% reduction are able to have at least one         $0 premium option to choose from.  This is the most confusing part of the levels of extra help and           the best way to know is to call us

     Copay Amount: Level 1, 2, 3, or 4. 2021 amounts are as follows:

           * Level 3 is the absolute best but it is rare.  Copays are reduced to $0 for both generic and brand.                Deductible is reduced to $0.

           * Level 2 the second best.  Copays are reduced to $1.30 per generic and $4.00 for brand.                              Deductible is reduced to $0.

           * Level 1 is by far the most common.  Copays are reduced to $3.70 for generic and $9.20 for                        brand.  Deductible is reduced to $0.

          * Level 4 is the least beneficial.  Copays are reduced to 15% of the total price for both              generic and brand.  Deductible is reduced to $92.  If the total price is $100 then you              pay $15 after deductible.

          COPAY LEVEL NOTE: Generally speaking, you can never pay more than the listed copay for the drug plan you are on.  For example, if you have a generic tier 1 medicine and the copay is $1 with no deductible and you have extra help copay Level 1 which says the copay is $3.70 for generics, you will still pay $1 because it is lower (unless you fall into the coverage gap and then it is different plan copay to compare the extra help copay to).  As you can imagine, this gets confusing fast, especially when you have numerous meds, and it is best to let us analyze it.  However, the bottom line is worth repeating.  The extra help copay applies unless your drug plan copay is lower.

LOSING EXTRA HELP: Many times people lose Extra Help without realizing it (this usually happens at the beginning of the year).  In some cases, they can get it back, but they just have to reapply assuming they still qualify.  It is easy to miss this and assume you can't get it.  Don't do that.  Let us analyze your situation and possibly reapply.  Or worse, so many people do nothing simply because they don't understand what they have and how it works.  Call us to discuss.

Medicaid (QMB) & Partial Medicaid (SLMB & QI)

Many people get this program confused with Extra Help.  Technically, you can get Extra Help by applying for Medicaid, but they are separate programs and most people get Extra Help by applying directly.

This Medicaid is different than traditional Medicaid which is used for people with no insurance.  Instead, this Medicaid (QMB, SLMB, & QI) is solely for people with low income and assets who are on Medicare.

This program is not run, or administered, at the federal level.  So you don't apply at Social Security, like Extra Help, or with Medicare.  You apply at your local Health & Human Service office (AKA Medicaid office).  Each state calls their Medicaid something different.  Oklahoma calls it Soonercare.  Texas just calls it Texas Health & Human Services, or Medicaid, and doesn't have a fancy name.  California calls in CalMed, etc.  Interestingly, most don't know that the technical name is actually 'Medicare Savings Program'.  Applicant award or denial letters will use this term even though that term is lesser known.

Medicaid is generally more challenging to get than Extra Help: Applications are longer, agency questions come for often, decision times are longer, denials seem to come easier, reenrollment is generally more frequent.  Also, it is more common in our experience for enrolees to get removed from Medicaid without knowing why, only to have to reapply and seemingly there was no problem because they get right back on it (that whole process often takes several weeks or longer).

You can apply in person at your local Health & Human Service office, by a requested paper application, or online at YourTexasBenefits.com (for Texas Medicaid only).

BENEFITS:  If you qualify, QMB or higher allows you full Medicaid (also known as Full Dual or Dual Eligible), which means the following:

     * Part B Premium Paid ForThe state Medicaid office will pay your Medicare Part B Premium in full each                  month

     * Zero Cost-Sharing:You qualify of zero cost sharing, meaning all your copays, coinsurance, & deductibles will              be paid in full provided you go to a provider who accepts your state Medicaid (providers out of state can't accept          Medicaid since it is state specific)

INCOME & ASSET LIMITS: The income limit to qualify is 138% of federal poverty level (FPL) but your state Medicaid will count your whole family income.  Also, you can't have too many assets not including your primary residence home, one vehicle, and basic personal belongings like furniture and such (valuables like expensive jewelry should be disclosed.  Income and asset limits almost always adjust slightly upward for inflation every year.  For 2021, the threshold that you can't go over are a little over $7,500 for single and $11,500 for couples.  If you have dependents, then asset and income limits go up.  

 

Interestingly, not all taxable income is counted the same.  Income from Social Security, pension or retirement, investments, mineral leases, home rentals, & most other income is counted dollar for dollar.  However, any kind of wages, meaning your working and paying payroll taxes, is only counted as a little less than half.  That doesn't mean they take money from you, just that the wages you earn don't fully count against your income limit of 138% FPL.  For example, if you get monthly income of $1000 in Social Security and approximately $1200 from your job, your total will not add up to $2200 since your wages are not fully counted against you.  The only way to know for sure if you qualify is to turn in an application and wait for a decision.  However, we can estimate your chances of qualifying and advise you if it is worth applying.  Once you know your exact income from all sources, the application does take some time (30 minutes to 1 hour) or longer if you are missing information.

Drug Discount Programs (other than Extra Help)

Other

COMING SOON!