CMS said on a conference call with SHIPs that individuals should NOT wait to enroll. If they are determined eligible for the subsidy after their plan coverage starts, the Plan will reimburse them for any expenses made out of pocket (CMS will notify plans of those awarded the Extra Help). Keep in mind that this does not affect duals, who are automatically eligible for the Extra Help and do not need to apply.

People automatically eligible for the Extra Help do not have to apply for assistance. These include consumers who have both Medicare and Medicaid (known as "dual eligibles"), people with Medicare who receive Supplemental Security Income (SSI), and people with Medicare who are in a Medicare Savings Program.

People with Medicare and Medicaid (known as "dual eligibles") and all other consumers with incomes below 150% of the Federal Poverty Level (FPL) are eligible for Extra Help. If your annual income is below $14,355 if you are single or $19,245 if you are married and living with your spouse, then you may qualify for Extra Help. These amounts may be higher if:

• You provide at least half of the support for relatives living in your household
• You reside in Alaska or Hawaii
• You are working

There are also income exclusions for the working blind and disabled.

To get the Extra Help with Medicare prescription drug costs, your countable resources (the value of things you own) generally must be valued below $11,500 (or $23,000 if you are married and living with your spouse). The limits include $1,500 per person for burial expenses.

Some examples of countable resources are:

• Real estate (other than your primary residence)
• Bank accounts, including checking, savings and certificates of deposit
• Stocks and bonds, including U.S. Savings Bonds
• IRAs and mutual funds
• Cash held at home or anywhere else

Some examples of things that are not counted as resources include:

• Your primary residence and vehicle
• Your household goods and personal possessions
• Resources you could not easily convert to cash, such as farm machinery and livestock, jewelry and home furnishings
• Federal income tax refunds
• Property you need to support yourself, such as land you use to grow produce for home consumption or rental property
• Life insurance policies with a combined value of $1,500 or less per individual (or $3,000 combined for a couple)

1. Help consumers determine if they qualify for Extra Help, also called the low-income subsidy, and assist them with an application. Providers should meet with consumers to make sure they have submitted an application or check their Medicare and Medicaid ("dual eligible") status to ensure they are automatically enrolled for the Extra Help. Applications should be submitted sooner rather than later to ensure timely processing before December 31, 2005.
2. Ask consumers if they have received the results of their application for Extra Help, if submitted, or notified that they will automatically qualify for the Extra Help. If person with Medicaid and Medicare has not received a notice by September 2005, the provider and the consumer should contact their SSA or local Medicaid office.
3. Once a consumer has the Extra Help determination, the provider should identify if the consumer knows his/her assigned plan and should review costs. Make sure consumers know that Medicare will only cover the lowest Medicare Prescription Drug Plan premium. If a plan is chosen with a higher premium, consumers will still be responsible for the difference, despite their income status.
4. In reviewing costs with consumers, providers should also discuss the impact of the Extra Help on the consumer's housing, food stamp benefits, and Medicaid Spend Down, as applicable. The reduction in medical spending will affect eligibility of other benefit programs.

If a consumer did not receive a letter from SSA but thinks he or she may qualify for financial help, he or she can call 1-800-772-1213, visit www.socialsecurity.gov, or apply at a State Medical Assistance office. The consumer will be notified in two to three weeks if they qualify for additional assistance. Contact local SSA or State Medicaid agency for applications and additional information.

Even what may seem like the smallest co-pay can still be very expensive for consumers on a fixed budget. The co-pays can range from one dollar for full-benefit dual eligibles to out-of-pocket costs in the thousands, depending on the consumers' drug needs. Pharmacies are permitted to waive or reduce cost-sharing to consumers that qualify for the Extra Help on a routine basis and for other people with Medicare on a non-routine basis. Pharmacies are restricted from advertising that they may waive costs, so providers should prompt consumers to ask for extra assistance. Another alternative for coverage of co-pays is through charitable organizations, state pharmacy assistance plans, or pharmaceutical company assistance programs.

It is important to note that 340B pharmacies that are in community mental health centers, federally qualified heath centers, or other publicly funded settings that waive costs do not count these fees toward the consumers TrOOP (true out-of-pocket expenses).

State Pharmacy Assistance Programs (SPAPs)
SPAPs are state-sponsored programs that provide senior citizens and individuals with disabilities increased access to prescription drugs by paying for or reducing costs for drug coverage.

Some states may have additional funds for prescription drug coverage because they will not be paying for the costs of medications for patients with both Medicare and Medicaid (known as "dual eligibles") any longer. They can use these additional funds to "wrap around" the Medicaid benefit for individuals to fill in any gaps in coverage.

The MMA defines an SPAP as a state program that provides financial assistance for supplemental prescription drug coverage for Part D eligible individuals. The states have two options:

• Supplement coverage by providing its own state supplemental benefit program or purchasing additional benefits through private insurance plans.
• Contribute to cost-sharing that will count toward the beneficiary's true out of pocket expenditures (i.e., the beneficiary would reach catastrophic coverage sooner).

State Health Insurance Assistance Programs (SHIP)
SHIPs fill the vital role of supporting a national network of community-based programs that provide locally accessible counseling and enrollment assistance services to people with Medicare.

Additional information can be found at www.shiptalk.org.

Program of All-Inclusive Care for the Elderly (PACE)
PACE is a unique managed care benefit that exists in certain areas in the U.S. and provides a medical and social service delivery system through a non-profit or public entity, combining Medicaid and Medicare financing. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services rather than be institutionalized. Capitated financing allows providers to deliver all services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems.

Final rules for Part D try to ensure that the new prescription drug benefit will not be disruptive to PACE organizations or enrollees. Additional guidance from CMS is forthcoming.

Charitable Organizations
Additional financial assistance may be available through charitable organizations locally and nationally.