Part D EXTRA HELP for 2013

Requirements to Become Eligible for Extra Help

This reviews the two main requirements for the Part D low income subsidy (LIS), that is, “Extra Help,” for the next calendar year, 2013, and also indicates what the basic structure of the Part D benefit looks like for those who qualify for it during 2013. The two main requirements are, of course, low income and few resources. And the new resource and income limits for 2013 have just been announced.

In 2013 you can qualify for Extra Help if your income is at or below $17,235 AND your resources are at or below $13,300 for an individual; or if your income is at or below $23,265 AND your resources are at or below $26,580 for a couple. Remember that neither your home nor your car or vehicle count as resources. And it has been said a thousand times before, but bears repeating, if your income or resources are ANYWHERE near these limits, apply, because there are many, complex rules as to what counts as income and what counts as resources, and as to how these are calculated if additional people live in your household. (And note that all the income levels are higher in the states of Hawaii and Alaska than we show here.)

All this is fully explained in Chapter 7 (which begins on page 99) of Managing Your Medicare.

And to summarize before we get into the details, if you do qualify for Extra Help, it will pay all or part of your Part D monthly premium, all or part of your annual deductible, and will eliminate or reduce your co-payments on drugs. (Full payment of the premium is restricted to plan premiums which are at or below the “benchmark” premium for your state. The benchmark premiums for each state for 2013 are shown the end of this text.) The specifics are as follows:

Basic Structure of the Extra Help Benefit in 2013

Those who qualify for Extra Help at these levels will pay no premium, and will not be subject to the deductible, and the cost of their drugs will be as follows:

If you have Medicaid AND:

You live in a nursing home or are in a community-based waiver program:

You pay nothing.


Your income is at or below $11,490 (individual) or $15,510 (couple):

You pay $1.15 for a generic or preferred brand, and $3.50 for a non-preferred brand.*


Your income is above $11,490 (individual) or $15,510 (couple):

You pay $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand.*


If you don't have Medicaid but your state helps you pay your Medicare premiums (that is, you are in the “Medicare Savings Program”) OR you get supplemental security income (SSI):

You pay $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand.*


If you are not in the categories above, but you qualify for Extra Help because your income and resources levels are as shown below, the cost of your drugs will be as follows, and you will be subject to an annual deductible and monthly premium payments as follows:


If your income is below $15,512 (individual) or $20,939 (couple) and your resources are at or below $8,580 (individual) or $13,620 (couple):

You pay $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand.* You pay neither a premium nor a deductible.


If your income is below $15,521 (individual) or $20,939 (couple) and your resources are at or below $13,300 (individual) or $26,580 (couple):

You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible.** You pay no premium.


If your income is at or below $16,086 (individual) or $21,714 (couple) and your resources are at or below $13,300 (individual) or $26,580 (couple):

You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 25% of your premium.**


If your income is below $16,661 (individual) or $22,490 (couple) and your resources are at or below $13,300 (individual) or $26,580 (couple):

You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 50% of your premium.**


If your income is below $17,235 (individual) or $23,265 (couple) and your resources are at or below $13,300 (individual) or $26,580 (couple):

You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 75% of your premium.**

*If your “drug expenses” ever exceed $4,750 in 2013, you will pay nothing for any prescription. (These are “Full Subsidy” beneficiaries.)

**If your “drug expenses” in the year ever exceed $4,750 in 2013, you will pay not more than $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand. (These are “Partial Subsidy” beneficiaries.)

Note on resource limits: Technically, the resource limits are $7,080 for an individual and for $10,620 a couple for “Full Subsidy” beneficiaries, and $11,800 for an individual and $23,580 for a couple for “Partial Subsidy” beneficiaries. However, in practice, when determining resources for Extra Help, the Social Security Administration allows a burial expense allowance of $1,500 for an individual or $3,000 for a couple, so these resource limits are almost always shown as $8,580 for an individual and $13,620 for a couple for “Full Subsidy” beneficiaries, and $13,300 for an individual and $26,580 for a couple for “Partial Subsidy” beneficiaries, and these adjusted limits are the ones shown above.

Benchmark Premiums for 2013

This is the most that Extra Help will pay for a premium in each state. If you choose a Part D drug plan with a monthly premium higher than this, you will have to pay all of the difference between these amounts and the premium. (Note that, depending on a plan’s formulary and pricing structure, this might possibly be cheaper for an Extra Help beneficiary than choosing a plan whose premium is below the benchmark.)

Alabama $33.70; Alaska $34.70; Arizona $29.40; Arkansas $34.10; California $29.90; Colorado $31.90; Connecticut $31.30; Delaware $35.00; District of Columbia $35.00; Florida $24.80; Georgia $34.20; Hawaii $33.30; Idaho $42.10; Illinois $30.90; Indiana $37.20; Iowa $34.60; Kansas $36.00; Kentucky $37.20; Louisiana $37.30; Maine $33.50; Maryland $35.00; Massachusetts $31.30; Michigan $34.20; Minnesota $34.60; Mississippi $34.60; Missouri $34.60; Montana $34.60; Nebraska $34.60; Nevada $20.30; New Hampshire $33.50; New Jersey $37.00; New Mexico $22.50; New York $43.20; North Carolina $32.00; North Dakota $34.60; Ohio $29.90; Oklahoma $32.80; Oregon $37.50; Pennsylvania $36.60; Rhode Island $31.30; South Carolina $38.70; South Dakota $34.60; Tennessee $33.70; Texas $31.80; Utah $42.10; Vermont $31.30; Virginia $30.10; Washington $37.50; West Virginia $36.60; Wisconsin $38.20; Wyoming $34.60.