Turning 65? Here’s How Extra Help and Medicaid Can Lower Your Medicare Costs

Understanding the Extra Help Program for Medicare Part D

Starting Medicare at 65 can feel like opening a new toolbox — but without the right tools, fixing anything is tough. Extra Help is one of those key tools. Think of it like a checklist that makes sure you’re not overpaying for prescriptions. If you qualify, the savings can add up quickly and give you peace of mind at the pharmacy.

✅ What Extra Help Actually Covers

💬 Grace, a Bible study host from her local church, shares:
“I didn’t think Extra Help would save me much — until my prescriptions dropped from $47 to $4. That’s when I realized how big a difference it makes.”

Here’s what Extra Help gives you in 2025:

📦 Premium Assistance

• Covers part (or all) of your monthly Part D premium
• Can save up to $103 per month
• Applies to whichever prescription drug plan you pick

💳 Reduced Deductibles and Copays

• $0 deductible (instead of the $590 standard)
• Lowers copays to just $4.50 for generics and $11.20 for brand names
• No “donut hole” or coverage gap to worry about

💡 Who Qualifies for Extra Help in 2025

Not sure if you’d make the cut? Here are the updated limits for 2025:

💵 Income Limits

• Single seniors: up to $22,590 per year
• Married couples: up to $30,660 per year
• (Alaska and Hawaii allow higher limits)

🏦 Asset Limits

• Singles: up to $17,220 in resources
• Married couples: up to $34,360 in resources
• Your home, car, and personal belongings don’t count toward this

🔍 How Caregivers Can Help With Applications

Caregivers often wonder how much they can step in to help loved ones apply. Here’s a quick breakdown:

👩‍👩‍👦 What Caregivers Can Do

• Fill out the application on behalf of their loved one
• Attend appointments as authorized representatives
• Gather bank statements and proof of income
• Communicate with Social Security (with written permission)

⚖️ What Requires Legal Authority

Accessing private Medicare accounts without authorization

Signing legal documents without power of attorney

Picking a Medicare plan without being a designated rep

How Medicaid Works with Medicare at Age 65

Starting Medicare can sometimes feel like diving underwater without clear vision. Medicaid acts like a snorkel mask 🥽 — it lets you see clearly and breathe easier while exploring the deep waters of healthcare costs. When combined with Medicare, Medicaid helps you cut through the confusion and keep your money in your pocket.

🏥 The Basics of Dual Eligibility

Here’s how it works when you qualify for both:

• Medicare is your primary insurance (covers hospitals, doctors, and prescriptions).
• Medicaid acts as secondary coverage (pays what’s left over).
• Together, they can wipe out nearly all out-of-pocket costs.
• You don’t have to juggle bills — coverage coordination happens automatically.

📊 Dual Coverage Benefits Comparison

Here’s a side-by-side look at how having both programs makes a difference:

🌟 Understanding Full vs. Partial Dual Eligibility

🟢 Full Dual Eligibility (FBDE)

• Medicaid pays premiums, deductibles, and copays
• Eligible for Special Needs Plans (D-SNPs)
• $0 cost-sharing for Medicare-covered services

🟡 Partial Dual Eligibility

• Helps with Medicare premiums only
• May still have some copays or deductibles
• Can access Medicare Savings Programs

💡 Extra Help works alongside Medicaid — cutting down your prescription costs so you can focus on your health, not your bills. Palmetto Mutual can walk you through both applications to make sure you don’t leave savings on the table.

Income and Asset Limits for Extra Help Eligibility

Think of Extra Help eligibility like pulling back a curtain on stage 🎭 — what you see at first glance may not be the whole story. Many seniors assume their income is too high or their savings too much, but the government uses a very specific formula to decide. Knowing what counts (and what doesn’t) can be the difference between paying full price and saving thousands each year.

💬 Brenda, a lifelong farmer, shares:
“I thought Medicare costs were the same for everyone. I paid full price for my prescriptions until a neighbor mentioned Extra Help. After applying, I realized I qualified and began saving hundreds each year. I wish I’d known at the start — it would’ve saved me a small fortune.”

💵 Behind the Curtain: What Counts as Income

Counted as Income

• ✅ Social Security benefits
• ✅ Pension payments
• ✅ Interest and dividends
• ✅ Rental income
• ✅ Veterans benefits (with some exceptions)

Not Counted as Income

• ❌ SNAP (food stamps)
• ❌ Home energy assistance
• ❌ Disaster relief funds
• ❌ Housing assistance
• ❌ The first $20 of your monthly income

🏠 Assets They Count vs. Assets They Ignore

Counted Assets

• 💰 Bank accounts (checking and savings)
• 📈 Stocks, bonds, and mutual funds
• 🏦 Investment accounts
• 🚗 Second vehicles
• 🏡 Second homes or rental property

Excluded Assets

• 🏠 Your main home
• 🚗 One vehicle
• ⚰️ Burial plots and funds (up to $1,500)
• 🛋️ Furniture and household items
• 📜 Life insurance policies

💊 How Plan Choice Affects Your Savings

Picking the right plan matters when using Extra Help:

SilverScript (Aetna / CVS)

• Often the lowest premium option for Extra Help recipients
• CVS pharmacy network is convenient in many ZIP codes
• Formularies (covered drugs list) change yearly — always review

Other Popular Options

• Wellcare → strong drug list (good for chronic conditions)
• Humana Basic → broad pharmacy network nationwide
• Clear Spring → better for seniors who need brand-name meds

👉 The bottom line: Don’t assume you’re not eligible. Extra Help rules are written to include more seniors than you might think — and even small savings add up fast.

Medicaid Programs That Cover Medicare Premiums

Medicare costs can feel like trying to balance on a bike for the first time 🚲 — wobbly and uncertain. That’s where Medicare Savings Programs (MSPs) come in. They act like training wheels, steadying you until you’re confident with your coverage and helping you avoid costly falls.

🎯 Four Levels of Medicare Savings Programs

Each MSP helps in a different way depending on your income:

🟢 QMB (Qualified Medicare Beneficiary)

• Covers Part A and B premiums
• Pays deductibles and coinsurance
• Income limit: $1,255/month (single)

🟡 SLMB (Specified Low-Income Medicare Beneficiary)

• Pays Part B premium only
• Income limit: $1,509/month (single)

🔵 QI (Qualifying Individual)

• Pays Part B premium only
• Income limit: $1,696/month (single)
• Must reapply every year

🟣 QDWI (Qualified Disabled Working Individual)

• For disabled workers under 65
• Covers Part A premium only
• Higher income limits apply

📈 The Real Cost Impact: Monthly vs. Annual Savings

💬 Helen, an independent widow, shares:
“I thought I earned too much to qualify, but my husband’s income counted separately after he passed. He never paid a premium, and now I don’t either. It was such a relief.”

Here’s a breakdown of what MSPs can save you:

🚀 How to Apply in Your State

Applying is simpler than most seniors expect:

• 📞 Call your State Medicaid office
• 🖥️ Apply through Social Security (for QMB/SLMB)
• 🧑‍💼 Get free help from SHIP counselors
• ☎️ Work with a licensed Medicare advisor like Palmetto Mutual

💡 Even if you think your income is too high, it’s worth checking — many seniors qualify after retirement when income drops.

How Extra Help Reduces Prescription Drug Costs

Prescription costs can eat away at a retirement budget faster than most seniors expect. Extra Help works like a coupon book you never have to clip ✂️ — lowering your costs automatically at the pharmacy counter. Let’s break down exactly how much you can save.

💊 Breaking Down the Real Savings

Here’s what the numbers look like before and after Extra Help:

❌ Before Extra Help

• Monthly Part D Premium: $35–$100
• Annual Deductible: $590
• Initial Coverage: 25% of drug costs
• Coverage Gap (Donut Hole): 25% of costs
• Catastrophic Coverage: 5% of costs

✅ With Full Extra Help

• Monthly Premium: $0
• Annual Deductible: $0
• All Stages: $4.50 generics / $11.20 brands
• No coverage gap
• No catastrophic threshold

📊 Before & After Savings Snapshot

🔤 Medicare Terms Explained Simply

Some confusing terms made easy:

• 📖 Formulary → Your plan’s list of covered drugs (like a menu at a diner).
• 📝 Prior Authorization → Getting approval before certain prescriptions can be filled.
• 📊 Tier → A drug’s category that sets your copay (Tier 1 = cheapest generics).
• 🍩 Donut Hole → The old “gap” in coverage that Extra Help eliminates.
• 💵 TrOOP → True out-of-pocket costs that count toward catastrophic coverage.

💡 With Extra Help, your pharmacy bill is simpler, lower, and more predictable — and Palmetto Mutual’s advisors can check today if you qualify.

Applying for Medicaid as a New Medicare Beneficiary

Medicare covers a lot, but not everything. That’s where Medicaid steps in like a filter 🪣 — catching the costs that would otherwise slip through the cracks. For many seniors turning 65, applying for Medicaid alongside Medicare makes the difference between struggling and staying secure.

💬 Carol, a retired school bus driver, shares:
“I drove a school bus for 30 years, but after retiring, every medical bill felt like a strain. I didn’t know I could have both Medicare and Medicaid until I spoke to a benefits counselor. Now my premiums and copays are covered, and I’m finally breathing easier.”

📅 Timing Your Medicaid Application

Best Times to Apply

• 🗓️ 3 months before turning 65
• 🩺 During your Initial Enrollment Period
• 🔄 After a qualifying life event (like losing other coverage)
• 📉 Any time your income drops

Documents You’ll Need

• Proof of income (last 3 months)
• Bank statements
• Medicare card (if already enrolled)
• Social Security award letter
• Proof of assets/resources

🏥 Making Sure Your Doctors Accept Medicaid

Not all doctors and hospitals take Medicaid, so it’s important to check:

Finding Participating Providers

• Search your state’s Medicaid provider directory
• Ask your current doctors directly
• Look for Federally Qualified Health Centers (FQHCs)
• Consider Dual Eligible Special Needs Plans (D-SNPs)

Network Considerations

• Some doctors limit the number of Medicaid patients
• Specialists may have longer wait times
• Hospital networks vary by state
• D-SNPs often include broader provider lists

⚡ Fast-Track Options for Quicker Coverage

Some states offer Presumptive Eligibility so you’re not left unprotected:

• ⏱️ Temporary Medicaid starts immediately while your application is processed
• 📄 Based on a quick income screening
• 🚑 Covers emergency and essential services right away

👉 Medicaid can feel overwhelming, but with the right guidance, it’s simply another safety net — making sure you don’t pay more than you have to.

Dual Eligibility: Qualifying for Both Medicare and Medicaid

Let’s be real for a minute — here’s the 60-second rant seniors need to hear. Dual eligibility isn’t charity, it isn’t welfare, and it’s nothing to be embarrassed about. You paid into the system your whole life, and these programs were built to help you.

💬 Irene, who helps her granddad with his side hustle, shares:
“I waited months before applying for Extra Help because I thought it was complicated. I didn’t realize I was paying full price when I didn’t have to. Now my costs are manageable, and I wish I’d applied the day I turned 65.”

🎯 The 60-Second Truth About Dual Eligibility

Too many seniors are cutting pills in half, skipping refills, or saying “no” to doctor visits because they think they won’t qualify or it’s too confusing. The truth?

• If you live mainly on Social Security, you probably qualify for something.
• Applications aren’t as bad as they look — especially with help.
• Savings can reach thousands of dollars per year.
• That’s money for groceries, grandkids, or just peace of mind.

Don’t let pride or paperwork cost you money you don’t have. These programs exist for you.

💰 Geographic Cost Differences That Matter

What you save can depend on where you live:

💵 ZIP Savings Example

• In Los Angeles, dual eligibles might get dental, vision, and transportation benefits worth $300+ monthly.
• In rural Kentucky, the same person might only get premium help worth $185/month.
• Add Extra Help, and an urban senior could save $500+ monthly, while rural seniors might save $250+ monthly.

👉 No matter where you live, the bottom line is the same: apply. Even smaller savings add up to thousands a year.

🔄 Special Enrollment Periods for Duals

When you’re dual eligible, you get extra flexibility:

⏱️ No need to wait until Annual Enrollment

🔃 Switch Medicare Advantage plans every 3 months

💊 Change Part D plans quarterly

↔️ Move between Original Medicare and MA

State-by-State Differences in Medicaid Medicare Assistance

Every state runs its Medicaid program a little differently — like a mirror reflecting the needs of its people. What you see in South Carolina might look very different from what shows up in New York or Texas. That’s why understanding your state’s rules is key when you’re turning 65.

🗺️ Why Your State Matters So Much

• 🌎 Expanded vs. Non-Expanded States → About 40 states expanded Medicaid under the ACA, which means higher income limits and more people qualify.
• ⚠️ Non-Expanded States → Stricter income rules and fewer benefits.
• 🕳️ Coverage Gaps → In some non-expanded states, seniors fall into gaps where they earn too much for Medicaid but not enough to afford care.
• 🏥 Benefits like transportation, dental, and vision can vary widely depending on state funding.

📊 Extra Help Eligibility Checklist

Here’s a simple checklist you can use when applying:

🏥 Prior Authorization Differences by State

Getting certain medications approved can also vary:

Understanding Prior Auth in Dual Plans

• Medicaid may override Medicare denials
• Formularies (drug lists) are state-specific
• Approval timelines can differ from state to state
• Emergency override rules also vary

Getting Medications Approved

• 📞 Work directly with your doctor’s office
• 📝 Know your state appeal rights
• 🧑‍⚖️ Use your state’s Medicaid ombudsman if needed
• 💊 Ask about emergency fills while waiting for approval

👉 Don’t leave savings unclaimed just because the rules seem confusing. Palmetto Mutual can help you navigate your state’s version of Medicaid and match it with Medicare for maximum benefits.

How to Apply for Extra Help Before or After You Enroll in Medicare

Filling out government forms can feel overwhelming, but having a swipe file 📂 — a ready-made checklist you can copy — makes it simple. Whether you’re already on Medicare or just turning 65, following these steps ensures you don’t miss a thing.

📝 The Application Swipe File: Copy This Process

Step-by-Step Template

Week 1: Gather Documents

• ☐ Last 3 months of bank statements
• ☐ Social Security award letter
• ☐ Investment account statements
• ☐ Life insurance policy values
• ☐ Pension statements

Week 2: Complete Application

• ☐ Go to SSA.gov/extrahelp or call 1-800-772-1213
• ☐ Keep all documents nearby
• ☐ Answer income questions (use gross amounts)
• ☐ List resources (remember exclusions like home & car)
• ☐ Submit application

Week 3: Follow Up

• ☐ Watch for determination letter
• ☐ Call if no response within 30 days
• ☐ Appeal if denied (you have 60 days)
• ☐ Reapply if your circumstances change

⏰ Timing Considerations for Different Scenarios

Already on Medicare

• Apply for Extra Help right away
• Benefits usually start the month after approval
• Retroactive coverage possible in some cases
• You can switch Part D plans if needed

Turning 65 Soon

• Apply up to 3 months before your birthday
• Line up with Medicare enrollment for a smooth start
• Benefits begin when your Medicare does
• Avoids coverage gaps at the pharmacy

💡 Understanding Plan G and Extra Help Interaction

Some seniors ask how Extra Help works if they also pick a Medicare Supplement like High-Deductible Plan G:

• Lower premiums ($30–50 vs $150+)
• Extra Help still covers Part D costs separately
• Works well for healthy seniors with savings set aside
• Annual deductible: $2,800 in 2025
• Makes even more sense if Medicaid pays the deductible

👉 Extra Help applications don’t need to be stressful. Having a template makes the process easier — and Palmetto Mutual can walk you through step-by-step so nothing slips through the cracks.

Next Steps if You Think You Qualify for Cost-Saving Programs

Navigating Medicare savings programs can feel like walking a tightrope 🎪 — one wrong step and you’re worried about falling into big medical bills. But with the right guidance, that rope has balance bars to keep you steady. Here’s how to take your next steps with confidence.

🎯 Your Priority Action Checklist

✅ This Week

• Calculate your monthly income
• List your countable assets
• Find your local Medicaid office phone number
• Schedule a benefits consultation

📅 This Month

• Submit your Extra Help application
• Apply for a Medicare Savings Program
• Review Part D drug plans with subsidies applied
• Set up authorized representatives if someone helps you with paperwork

🏢 Choosing Between Local and National Plans

🌎 National Plan Advantages

• Consistent benefits across states
• Better if you travel or split time with family elsewhere
• Often larger drug formularies
• Usually more stable year to year

🏡 Local Plan Benefits

• Local agents understand state Medicaid rules better
• Community-based customer service
• Partnerships with nearby hospitals and clinics
• Sometimes include extra benefits unique to the region

🚀 Making Your Benefits Work Together

Coordination Tips

• Always show both Medicare & Medicaid cards at appointments
• Know which program pays first
• Keep all approval letters organized
• Report income or asset changes quickly to both

Maximizing Your Savings

• Use in-network providers whenever possible
• Choose generic drugs for lower costs
• Take advantage of free preventive services
• Don’t forget OTC allowances (often $35–$50 monthly)

👉 With the right balance, you can move forward without fear — and Palmetto Mutual can be your safety net, making sure no savings slip away.