Do your Medicare patients qualify for Extra Help?
The Centers for Medicare & Medicaid Services (CMS) offers assistance to Medicare members for prescription drug coverage known as the Low-Income Subsidy (LIS) or Extra Help. Many members who qualify for LIS routinely don’t apply and receive it. You can help your Medicare patients afford the care they need by raising awareness of this program.
What exactly is LIS?
LIS, also known as Extra Help, is a Medicare program designed to help people with limited income and resources cover health costs, including prescription drugs. LIS was expanded as part of the Inflation Reduction Act in 2022. Medicare members who qualify can receive benefits up to and including:
- $0 Medicare drug plan premium
- $0 health plan deductible
- Paying no more than $4.50 for each generic drug
- Paying no more than $11.20 for each brand-name drug
- Paying $0 for each covered drug once total drug costs (including certain payments made on the member’s behalf, like through LIS) reach $8,000
Who qualifies?
There are two scenarios for Medicare members to qualify for LIS:
| Members automatically qualify if they… | Members should apply if they… |
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*Note that these specific qualifications are for 2024 and may change in 2025 and beyond.
Members who qualify receive a one-time letter informing them of their benefits. They will receive letters in subsequent years only if they no longer qualify for LIS, if their LIS benefits change or if they move to a different plan.
What’s the impact on you?
LIS helps members get the care they need through financial support. If you’re a care manager, you especially will benefit from using it as a tool.
By removing cost barriers for prescription drugs specifically, LIS can support increased medication adherence, which will in turn increase your PCP Incentive Program (PIP) rewards.
What can you do?
Care managers and other providers can help Medicare patients determine if they may qualify and apply for LIS benefits. More information and the link to the application can be found at medicare.gov/basics/costs/help/drug-costs.
Note that, to apply, members may need the following documents:
- Social Security card
- Bank account statements, including checking, savings and certificates of deposit
- Individual Retirement Accounts (IRA), stocks, bonds, savings bonds (including book entry securities), mutual funds and other investment statements
- Tax returns
- Payroll slips
- The member’s most recent Social Security benefits award letters or statements for Railroad Retirement benefits, Veterans benefits, pensions and annuities
Telephonic outreach may be most effective, so that the member can access these documents at home as you help them through the application process.
What about members who fear the stigma of low-income subsidies?
Some members will be hesitant to apply because of the stigma associated with receiving government assistance. Here are a few talking points to share with members with these concerns:
- The cost of health care, and prescription drug costs in particular, are increasing quickly, making it harder for average Americans to afford the medicine they need
- LIS, or Extra Help, is simply a small add-on to the Medicare plan they’re already enrolled in; it is not an entirely separate program
- Part of the goal of expanding LIS through the Inflation Reduction Act was to bring these benefits to a larger portion of seniors—not just those at the lowest income levels
- Once the member qualifies, LIS benefits apply directly to the member’s plan, so there’s no need for a member to “announce” they have LIS when, say, picking up their prescriptions
- Simply using the name Extra Help instead of Low-Income Subsidy may make the program more appealing to more members