KBenefits Medicare Services
Extra Help - PAAD

Medicare Part D - Extra Help Program
 

What is Extra Help?

Part D prescription drug coverage is available for any Medicare beneficiary. Extra Help is a program within Medicare that assists individuals with the cost of their Part D prescription drug plan. Some Medicare beneficiaries with limited resources and income are eligible for the Extra Help program.

 

What does Extra Help cover?

Extra Help assists eligible beneficiaries with paying for costs associated with their Medicare Part D prescription drug plan, like annual deductibles, monthly premiums and prescription co-payments or coinsurance.

 

How Much Will You Pay In Extra Help?

With the full Extra Help benefit in 2018, an eligible beneficiary should pay no more than $3.35 for a generic drug (or a brand-name drug treated as a generic) and $8.35 for any other brand-name drug. For those qualifying for partial Extra Help, an eligible beneficiary should pay no more than 15 percent of the cost of drugs on your plan’s formulary (or list of covered drugs)–or the plan copay, whichever is less—until you reach the out-of-pocket maximum. Most people who qualify for Extra Help also pay nothing, or a reduced amount, for their monthly premium and annual deductible.
 

Medicare enrollees who have Medicaid, live in an institution like a nursing home, or receive home and community-based services should not be paying anything out of pocket for their prescription drugs.

 

How to Qualify for Extra Help

Many Medicare beneficiaries qualify for Extra Help and don’t even know it. To qualify for Extra Help:
 

1)  You must been rolled in a Medicare Part D prescription drug plan.

2)  You must reside in one of the 50 states

3)  Your annual income must be less than $18,090 for an individual or $24,360 for a married couple living together. Even those individuals or couples with incomes exceeding the threshold may still be eligible for assistance .

4)  Your resources cannot exceed $8,890 for an individual or $14,090 for a married couple who live together to receive full Extra Help, or $13,820 for an individual or $27,600 for a married couple who live together to receive partial Extra Help. Resources include:  bank accounts, stocks and bonds. Resources do not include: your home, your car, or life insurance policies.

 

How to Apply for Extra Help

To apply for Extra Help, you must complete Social Security’s Application for Extra Help with Medicare Prescription Drug Plan Costs (SSA-1020). You can apply in the following ways:
 

•  Apply online at www.socialsecurity.gov/extrahelp

•  Call Social Security at 1-800-772-1213 to apply over the phone or to request an application;  or
•  Apply at your local Social Security office.

 

Pharmaceutical Assistance to the Aged & Disabled (PAAD)

The Pharmaceutical Assistance to the Aged and Disabled (PAAD) program is a state-funded program that helps eligible seniors and individuals with disabilities save money on their prescription drug costs.

You may be eligible for PAAD if you meet the following requirements:

  • You are a New Jersey resident;
  • You are age 65 or older or between ages 18 and 64 and receiving Social Security Title II Disability benefits; and
  • Your income for 2021 is less than $28,769 if single or less than $35,270 if married.
  • Medicare-eligible PAAD beneficiaries are also required to enroll in a Medicare Part D Prescription Drug Plan. PAAD will pay the monthly premium for certain standard basic Part D plans with a monthly premium at or below the regional benchmark. These plans will cover medically necessary prescription medications under Medicare Part D. If a beneficiary self-enrolls in an enhanced plan at or below the regional benchmark premium amount, PAAD will pay the premium as long as the plan agrees to follow all the billing requirements.
  • The federal Medicare Plan and/or PAAD will pay any costs above the PAAD copayment of $5 for each covered generic drug or $7 for each covered brand name drug, including premiums. However, if a Medicare Part D plan does not pay for a medication because the drug is not on its formulary, PAAD beneficiaries will have to switch to a drug on their Part D plan's formulary, or their doctor will have to request an exception due to medical necessity directly to their Part D plan. Medicare Advantage participants must add a prescription benefit to their coverage, and PAAD will contribute up to the regional benchmark amount towards the prescription portion of their total premium.


For more information call toll free 1-800-792-9745.
To learn more about how PAAD interacts with Medicare Part D -
Click Here

Information referenced from:  https://www.state.nj.us/humanservices/doas/services/paad/ox

Christopher S. Kudryk
Insurance Specialist
chris@kbenefits.com
732-333-1976

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