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HICAP is here to help.

Medicare can be expensive, and many beneficiaries need assistance paying for prescription drug related costs, or help with paying their Medicare premiums, co-payments, and co-insurance.

Federal, state and other programs can help you with your Medicare related costs. “Extra Help” is a prescription drug assistance program that can help you save money on plan premiums, deductibles and co-payments. “Medicare Savings Programs” can help pay for your Medicare Part A and B premium and some or all of your Medicare deductibles and co-payments.

The Health Insurance Counseling & Advocacy Program (HICAP) provides free, unbiased Medicare counseling to Medicare beneficiaries and their families and can help you apply for these programs.

Medicare Savings Programs

“Extra Help” / Low Income Subsidy (LIS)

Other Programs to Help with Prescription Drug Costs

What are Medicare Savings Programs?

Medicare Savings Programs help people with limited income by paying their Medicare Part A and B premium. These programs may also pay some or all of the Medicare deductibles and co-payments. You may qualify if your income meets eligibility criteria.

Medicare Savings Programs (MSP) are administered by County Social Services. Some beneficiaries may qualify for both Medicare Savings Programs and Medi-Cal, and others may qualify for one but not the other.

Who is eligible?

You must be eligible for Medicare in order to be eligible for any MSP. And, you must meet the income limitations displayed on the MSP Chart below.

If you qualify for QMB, SLMB or QI, you automatically qualify for Extra Help (Low Income Subsidy – LIS), which helps pay for Medicare prescription drug related costs such as plan premiums, deductibles and co-payments.

Qualified Disabled Working Individual (QDWI) Program is available to you if you are disabled, under age 65, and lost your premium-free Part A when you returned to work.

Eligibility is generally re-determined each year.

2024 MSP Summary Chart

Program Name	Benefits	Monthly Income Single/Married
Qualified Medicare Beneficiary (QMB)	Pays Part A & B premium Pays Medicare deductibles, copayments, coinsurance Does not provide 3 month retroactive Part B premium reimbursement You can have both Medi-Cal and QMB	$1,275 / $1,724
Specified Low-Income Medicare Beneficiary (SLMB)	Pays Part B premium Provides 3 month retroactive Part B premium reimbursement You can have both Medi-Cal and SLMB	$1,526 / $2,065
Qualifying Individual (QI)	Pays Part B premium Provides 3 month retroactive Part B premium reimbursement You cannot have both Medi-Cal and QI	$1,715 / $2,321
Qualified Working Disabled Individual (QDWI)	Pays Part A premium You cannot have both Medi-Cal and QDWI	$5,105 / $6,899

MSP Benefits and Protections

No Part B late enrollment penalty (waived for individuals that qualify for QMB, SLMB, and QI)
No estate recovery (states cannot ask for repayment for costs covered under the MSP from estates of deceased MSP recipients)
Beneficiaries eligible for MSPs automatically get Extra Help to cover prescription drug related costs
QMB recipients cannot be “balanced billed” (billed for co-payments/co-insurance)
Claims should automatically transfer from Medicare to Medi-Cal for processing

What is Extra Help (Low Income Subsidy – LIS)?

Extra Help is a prescription drug assistance program for people on Medicare who have limited income and assets. The program helps people pay for Medicare Part D premiums, deductibles, and co-payments.

You may qualify if your income and assets meet the following criteria.

Full Extra Help Coverage	Income Limit	Asset Limit
Individual	$1,903	$17,220
Married Couple	$2,576	$34,360

Who qualifies?

Some people automatically qualify for Extra Help, and others must apply for the program.

You automatically qualify –

If you are enrolled in both Medicare and full Medi-Cal
If you are receiving Supplemental Security Income (SSI)
If you qualify for a Medicare Savings Program (MSP)

Other programs to help Medicare beneficiaries lower their prescription drug costs.

Patient Assistance Programs (PAPs)	Some pharmaceutical companies offer programs that provide free or low-cost drugs to qualified individuals.
Annual Plan Reviews	Review your health plan options for potential cost savings during Medicare Open Enrollment (Oct. 15 – Dec. 7).
Generic vs. Brand-name Medications	Speak to your doctor about changing to a generic drug.
Mail Order Pharmacy	Check your health plan for mail order pharmacy options that may cost less.
Tiering Exception	Formally request your health plan to place a drug on a lower tier, lowering the cost of the drug.
CA Prescription Drug Discount Program	Get drugs at Medi-Cal rates plus a 15-cent processing fee at Medi-Cal participating pharmacies.
Samples	Speak to your doctor about getting samples if you are temporarily having trouble obtaining the drugs.
Waiving Co-Pays	Speak to your pharmacist about a case-specific waiver.
Charity Care Program	Ask at the hospital about charity care to help lower your drug costs.
Pharmacy Comparisons	Compare your prescription prices at different pharmacies. Although in-network pharmacies should have lower prices, there may be occasions when pharmacies outside the network have lower prices.

What if My Plan Denies Coverage?

Our Health Insurance Counseling & Advocacy Program (HICAP) counselors can help you understand the reason for the denial and can assist you with filing an appeal.

Your plan may deny coverage if:

Prior Authorization – required before your plan covers the drug
Step Therapy – your plan requires you to try a different drug first
Quantity Limits – your plan only covers a certain quantity of a drug over a certain period; e.g. 30 tablets per month
Off-Formulary – medication is not on the plan’s formulary
Off-Label – drug prescribed for reason other than approved by U.S. Food and Drug Administration (FDA)
Excluded – drug excluded from Medicare Coverage

Contact HICAP for Application Assistance

(800) 434-0222 or (714) 560-0424
OR
Contact your closest Senior Center to schedule an appointment with a local HICAP Counselor

HICAP does not sell, endorse, or recommend insurance products.

This product is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $202,853 with 100% funding by ACL/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.

This product is the result of a project funded by a contract with the California Department of Aging and administered by the Orange County Office on Aging.