Medicare Rx Extra Help Online Application

Should You Use This Application?     Need Help?

Since not everyone will be able to use the online Application for Extra Help with Medicare Prescription Drug Plan Costs, we need you to answer a few questions to help us figure out if you should use this application form. Any time there is a link at the end of a question that says "HELP," you can follow that link to get help with that question.

1.    If you are working with an agency, please select the agency from the list. If your agency is not listed or you are completing the questionnaire on your own, choose none of the above.
2.    Are you assisting someone (other than your spouse who lives with you) with this application?
Note: If you are completing this form for someone else other than your spouse, it is important that you answer Yes here. By answering Yes, we will be able to collect contact information from you later so someone can contact you if there are problems with this application. If you are helping another person fill out this application, answer the following questions as if you were the person.  HELP
      Yes   No
3.    Did you (or your spouse, if married and living together) get an application in the mail from the Social Security Administration?  HELP
      Yes   No
4.    Do you (or your spouse, if married and living together) have Medicare?  HELP
      Yes   No
5.    Are you (or your spouse, if married and living together) currently receiving benefits from or participating in any of the following public programs?  HELP
Medicare Savings Programs (QMB, SLMB, or QI)
Supplemental Security Income (SSI)
6.    Are you (or your spouse, if married and living together) 64 years and 9 months old or older?  HELP
      Yes   No
7.    Have you (or your spouse, if married and living together) received:
  • Social Security disability benefits for 24 months;
  • Disability benefits based on Lou Gehrig's disease (ALS); or
  • Renal dialysis treatments or a kidney transplant
  •  HELP
          Yes   No
    8.    In which state do you (and your spouse, if married and living together) live?  HELP
    9.    What is your marital status?  HELP
    10.    Do you have combined savings, investments, and real estate (other than the home you live in) worth more than:
  • $14,610 if you are not married or not living with your spouse; or
  • $29,160 if you are married and living with your spouse?

  • Include the things you own by yourself, with your spouse, or with someone else. DO NOT include the home you live in, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
    Note: Social Security excludes many different types of resources when figuring out a person's eligibility for the Extra Help. For a list of these exclusions, click on the HELP link.  HELP
          Yes   No or Not Sure