HI 03001: Description of the Medicare Prescription Drug Coverage Program

Effective Dates: 12/15/2017 - Present

TN 7 (10-09)

A. Extra Help and deemed subsidy eligibles

The Medicare Part D Extra Help program helps Medicare beneficiaries with limited income and resources pay for prescription drug coverage. Eligible beneficiaries receive subsidized premiums, deductibles, and copayments. Subsidized premiums are paid to the prescription drug provider (PDP) or Medicare Advantage prescription drug plan (MA-PD) by the Center for Medicare and Medicaid Services (CMS) and are based on the service area’s regional benchmark premiums. Extra Help eligibles with a full premium subsidy who choose to participate in a more expensive plan are responsible for the difference.

The Medicare Part D program assumes responsibility for prescription drug coverage for full Medicaid recipients with Medicare.

Certain beneficiaries are automatically deemed subsidy-eligible and should not complete an application for Extra Help. These beneficiaries have Medicare Parts A or B, or both, and are:

already entitled to Supplemental Security Income (SSI),
eligible for full Medicaid coverage, or
covered under one of the Medicare Savings Programs as a Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Individual (QI).

NOTE: 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.

B. SSA and Extra Help

If a beneficiary is not deemed eligible for Medicare Part D Extra Help, he or she 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 the applicable percentage of Extra Help premiums. An SSA eligibility determination indicates one of the following conditions:

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: 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.

NOTE: For information on the Extra Help appeal process, see HI 03040.001.

An SSA subsidy determination of an allowance 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.

A subsidy determination cannot be effective 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 eligibility for a full or partial subsidy. SSA redetermines eligibility for all Extra Help initial determinations made by SSA. More information about Extra Help redeterminations is available in HI 03050.011.

Effective January 2010, unless the claimant objects, SSA will transmit Extra Help determination data to the appropriate State Medicaid agency to begin the MSP application process.

C. CMS, deemed subsidy eligibles, and Extra Help eligibles

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; and
Sends SSA data to support requests for Part D premium withholding (or stops Part D premium withholding) from the Title II benefit.

NOTE: Deeming is a CMS activity; SSA does not make these determinations and cannot address any appeals of deeming decisions.

D. Deemed eligibility and applying for Extra Help

Medicare beneficiaries are automatically deemed subsidy-eligible and should not apply for Extra Help if they:

have Medicaid;
participate in a QMB, SLMB, or QI program; or
receive SSI.

Almost all Medicare Part D Extra Help applications are taken and processed by SSA. A prescribed subsidy application filed with us includes the:

SSA-1020-OCR, scannable paper version (HI 03010.035B.1.) in English and Spanish;
i1020, online version on SSA’s Internet website (HI 03010.035B.3.); or
Intranet via the Medicare Application Processing System (MAPS) screens completed by an SSA employee (HI 03010.010 and MSOM INTRANETMAPS 005.001 — MSOM INTRANETMAPS 005.013

State Medicaid agencies may use the Extra Help application, which may be a paper SSA-1020-OCR or i1020. However, if the Medicaid agency chooses to use a non-SSA application, the agency must process the application, make the subsidy determination (and subsequent annual redeterminations or appeals), and share applicable data with CMS directly. CMS shares the appropriate data with SSA. This is very rare.

E. Beneficiary contacts 800#, Field Office (FO), or Workload Support Unit (WSU)

The preferred method of filing for Medicare Part D Extra Help is through our online application, the i1020. Refer beneficiaries first to the online process at https://secure.ssa.gov/apps6z/i1020

1. 800# process

If a beneficiary calls and needs help with the Extra Help application or alleges that he or she did not receive a form but wants to file for Extra Help, 800# agents should follow the instructions in TC 24020.020.

2. FO and WSU process

If a beneficiary contacts the FO or and requires assistance completing the Extra Help application or alleges non-receipt of a form and wants to file for Extra Help, follow the instructions in HI 03010.001 through HI 03010.040.

F. Questions about enrollment

People who file an application and establish eligibility for Extra Help may or may not be enrolled with a PDP or MA-PD. Enrollment is generally effective the month after the enrollment request is filed with the PDP or MA-PD. (More information regarding specific enrollment periods and effective dates of coverage is found in HI 03001.001F.)

Extra Help beneficiaries who do not enroll with a PDP or an MA-PD are enrolled in a plan selected by CMS; however, they may choose not to be enrolled. For information about facilitated enrollment, see HI 03001.010.

Beneficiaries with questions about enrolling or choosing a PDP or MA-PD should call 1-800-MEDICARE (1-800-633-4227). The Medicare TTY number is 1-877-486-2048. Refer beneficiaries to their State Health Insurance Counseling and Assistance Program (SHIP) for assistance in choosing a PDP or MA-PD. SHIP telephone contact information is on the back of the “Medicare & You ” handbook or may be accessed by selecting the State at http://www.medicare.gov/contacts/organization-search-criteria.aspx .

G. Full and partial subsidies

An individual can qualify for a full or partial Medicare Part D subsidy depending on his or her income, resources (and those of the living-with spouse), and household size. The resources are compared to one of two resource limits for individuals and couples. A more detailed explanation of resource limits is in HI 03030.025.

Income is based on the Federal Poverty Level (FPL), which considers the number of persons in the household. To determine household size, a relative is considered in the same household as the beneficiary if the relative (by blood, marriage, or adoption) receives at least one-half support from the beneficiary or the living-with spouse. For more information about income and the FPL see HI 03020.055 and HI 03001.020C.

NOTE: When discussing Extra Help, it is important to remember that a person who receives a 100% premium subsidy is not necessarily “full subsidy eligible.” A person who fails to meet the lower resource standards may receive a 100% premium subsidy but may pay an annual deductible and higher copayments than a “full subsidy eligible” individual.

2018 resources standards chart for individuals/couples

	With Burial Exclusion	Without Burial Exclusion
Lower Resources Level	$9,060/$14,340	$7,560/$11,340
Higher Resources Level	$14,100/$28,150	$12,600/$25,150

The charts below explain the basic Part D benefit and the Extra Help available in 2018 and 2017 for each subsidy level and for non-institutional deemed eligibles. All resource limits shown include the $1,500 per person burial exclusion.

1. Part D coverage for 2018

For individuals/couples at 150% FPL or above, or with countable resources greater than $14,100/$28,150 or both (basic benefit)

If income is	150% FPL or above
And resources are	NONE to greater than resource limit for the year
The deductible is	$405
The copayment is	After deductible, 25% up to $3,750 in out-of-pocket drug cost
The coverage gap is	The beneficiary is responsible for 40% of out-of-pocket costs of brand-name drugs and 51% of out-of-pocket costs of generic drugs between $3,750 and $7,508.75. The beneficiary’s cost will continue to decrease each year until it reaches 25% by 2020 for both brand-name and generic drugs.
Catastrophic coverage applies	After $5,000 in total out-of-pocket covered drug costs are paid by the beneficiary (usually representing $7,508.75. in covered drugs), copayments of $3.35 for generic/preferred, and $8.35 for other covered medications

For individuals/couples not eligible for Medicaid, but between 136% and 149% of FPL (Low-Income Subsidy)

If income is	Between 136% and 149% FPL 25% premium subsidy from 146-149% 50% premium subsidy from 141-145% 75% premium subsidy from 136-140%
And resources are	$14,100 or less for individuals, $28,150 or less for couples
The deductible is	$83
The copayment will be	After deductible, 15% up to $5,000 in out-of-pocket drug costs
The coverage gap is	Covered – If the beneficiary is receiving Extra Help there is no coverage gap
Catastrophic coverage will apply	After $5,000 in out-of-pocket covered drug costs paid by beneficiary, copays of $3.35 for generic/preferred and $8.35 for other covered medications

For individuals/couples not eligible for Medicaid, but less than or equal to 135% of FPL (Low Income Subsidy)

If income is	Less than or equal to 135% FPL with higher resources level	Less than or equal to 135% FPL with lower resources level
And resources are	Greater than $9,060, but do not exceed $14,100 for individuals Greater than $14,340, but do not exceed $28,150 for couples	$9,060 for individuals, $14,340 for couples
The deductible is	$83	NONE
The copayment will be	After deductible, 15% up to $5,000 in out-of-pocket drug costs	$3.35 for generic/preferred and $8.35 for other medications
The coverage gap is	Covered – If the beneficiary is receiving Extra Help there is no coverage gap	N/A
Catastrophic coverage will apply	After $5,000 in out-of-pocket covered drug costs are paid by the beneficiary, and copays of $3.35 for generic/preferred and $8.35 for other covered medications	N/A

For non-institutionalized individuals deemed eligible for Extra Help

If income is	Over 100% FPL	Up to and including 100% FPL and full Medicaid eligible
And resources are	Limited by the rules of the qualifying program	Limited by the rules of the qualifying program
The deductible is	NONE	NONE
The copayment is	$3.35 for generic/preferred and $8.35 for other covered medications	$1.25 for generic/preferred and $3.70 for other covered medication
The coverage gap is	N/A	N/A
Catastrophic coverage is	N/A	N/A

2. Part D coverage for 2017

For individuals/couples at 150% FPL or above, or with countable resources greater than $13,820/$27,600 or both (basic benefit)

If income is	150% FPL or above
And resources are	NONE to greater than resource limit for the year
The deductible is	$400
The copayment is	After deductible, 25% up to $3,700 in out-of-pocket drug cost
The coverage gap is	The beneficiary is responsible for 45% of out-of-pocket costs of brand-name drugs and 58% of out-of-pocket costs of generic drugs between $3,700 and $7,425. The beneficiary’s cost will continue to decrease each year until it reaches 25% by 2020 for both brand-name and generic drugs.
Catastrophic coverage applies	After $4,950 in total out-of-pocket covered drug costs are paid by the beneficiary (usually representing $7,425. in covered drugs), copayments of $3.30 for generic/preferred, and $8.25 for other covered medications