“Every plan on the market was built with a weakness.”
Medicare Advantage $0 premium plans save money — until you need a specialist outside the network. Your blood work is $0. Then you have a cardiac event. A cancer diagnosis. A surgery that requires a specialist who isn't in your network. Now you're looking at an $8,300 out-of-pocket maximum, prior authorization delays, and a facility bill you didn't expect. The $0 premium plan isn't free — you'll find that out the hard way, or you won't.
Extra Help, also called the Low Income Subsidy (LIS), is a federal program that pays most or all of your Medicare Part D prescription drug costs — including premiums, deductibles, and copays. In 2026, full Extra Help beneficiaries pay no more than a few dollars per prescription and face a $2,100 annual out-of-pocket cap on drugs.
Source: SSA.gov / CMS.gov
For 2026, you may qualify for Extra Help if your income is at or below 150% of the Federal Poverty Level — approximately $22,590/year for a single person or $30,660/year for a couple. Resource limits are roughly $17,220 (individual) and $34,360 (couple), excluding your home, one car, and life insurance.
Source: SSA.gov Extra Help 2026 guidelines
Full Extra Help recipients in North Carolina save an average of $3,900–$5,900 per year on Part D costs. This includes $0 or very low monthly premiums, eliminated deductibles, and copays capped at $4.50 for generics and $11.20 for brand-name drugs in 2026.
Source: CMS.gov Medicare Savings Programs data
Yes. If you receive Medicaid, Supplemental Security Income (SSI), or participate in a Medicare Savings Program (MSP) in North Carolina, you are automatically enrolled in Extra Help — also known as 'deemed eligible.' You do not need to submit a separate application.
Source: Medicare.gov Extra Help overview
Here's what most people don't realize until it's too late: Many Durham County seniors on fixed incomes spend $300–$600 per month on prescription drugs. Without Extra Help, Part D deductibles, premiums, and copays stack up fast — especially for those managing diabetes, heart disease, or cancer medications.
Rob runs the numbers for all of it. Call 828-761-3326 or keep reading.
“Are you actually sure you understand what you're signed up for?”
Most people get buried in mail, carrier calls, and TV ads all saying the same thing. $0 premium. Free dental. None of it tells you what happens when you actually need care. That's a different conversation.
Many Durham County seniors on fixed incomes spend $300–$600 per month on prescription drugs. Without Extra Help, Part D deductibles, premiums, and copays stack up fast — especially for those managing diabetes, heart disease, or cancer medications.
Thousands of NC residents who qualify for Extra Help never apply because the eligibility rules seem complex. Many don't realize that certain assets — like your home, car, and life insurance — are excluded from resource calculations, making far more people eligible than they think.
Extra Help qualifiers get a Special Enrollment Period to switch Part D or Medicare Advantage plans at any time of year. But if you don't know you qualify, you could spend 12 months locked into a plan that charges full price for every prescription.
When CMS auto-assigns Extra Help recipients to a Part D plan, it may not be the plan that best covers your specific medications. Without guidance, you could pay more than you should even with Extra Help applied.
“What if you could see exactly what your plan costs before you ever needed it?”
Total annual cost equals premium plus deductible plus copays for your actual doctors and your actual drugs. Not the insurance company's estimate. Your actual situation, priced out before you sign anything. That's what a broker does. It's free. It takes 20 minutes.
Use the 2026 guidelines: single individuals earning up to ~$22,590/year and couples up to ~$30,660/year likely qualify. Resources (savings, investments) must be below ~$17,220 (individual) or ~$34,360 (couple). Your home, one vehicle, and life insurance are excluded. If you are unsure, call Robert Simm at (828) 761-3326 for a free eligibility review.
Before applying, collect: Social Security award letter or recent SSI notice, bank statements for all accounts, investment or retirement account statements, Medicare card, current Part D plan information, and proof of any pension or other income. Having these ready speeds up the application significantly.
You can apply for Extra Help three ways: (1) Online at SSA.gov/extrahelp; (2) By calling Social Security at 1-800-772-1213; or (3) In person at the Durham Social Security office. NC DHHS also accepts applications through the Medicare Savings Program, which may qualify you for Extra Help automatically.
Social Security will send you a written determination within 30 days. If approved, you will receive either full or partial Extra Help. Full benefit recipients pay no Part D premium (up to the benchmark plan cost), no deductible, and copays capped at $4.50 generic / $11.20 brand-name in 2026. Keep this letter — you may need it to enroll in the best plan.
Extra Help gives you a Special Enrollment Period to change your Part D plan at any time. This is critical — CMS may auto-assign you to a plan, but it may not cover your specific medications. Robert Simm can compare all available plans in Durham County against your drug list to find the one with the lowest true cost. Use the plan comparison tool at https://www.sunfirematrix.com/app/consumer/medicareadvocates/10447418/ or call (828) 761-3326.
Extra Help status is reviewed annually. If your income or resources change — or if you lose Medicaid or SSI — you may need to reapply. CMS also conducts annual redeterminations. Robert Simm sends annual review reminders to all clients in Durham County to ensure no one loses their benefit unexpectedly.
“A diagnosis. A surgery. A specialist who isn't covered.”
That's when the affordable plan starts costing thousands. The $0 premium plan has an $8,300 out-of-pocket maximum. One hospitalization hits $1,736 before Medicare pays a single dollar. The plan that looked smart in January becomes the plan you regret by March.
Extra Help (LIS) specifically reduces your Medicare Part D prescription drug costs — premiums, deductibles, and copays. The Medicare Savings Program (MSP) is a separate North Carolina program that helps pay your Medicare Part A and Part B costs, including the $202.90 Part B monthly premium and the $283 Part B deductible. Many people qualify for both programs simultaneously. Qualifying for MSP often automatically qualifies you for Extra Help as well.
For 2026, the income limits are approximately $22,590/year for individuals (150% FPL) and $30,660/year for couples. Resource limits are $17,220 for individuals and $34,360 for couples. Importantly, your primary residence, one vehicle, personal belongings, life insurance with face value under $1,500, and irrevocable burial contracts are all excluded from the resource calculation. These limits are reviewed annually by the Social Security Administration.
You can apply three ways: (1) Online at SSA.gov/extrahelp — the fastest option; (2) Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778); or (3) Visit the Durham Social Security Administration office in person. You can also apply through NC DHHS for Medicaid, which may qualify you automatically. Robert Simm at (828) 761-3326 can help you prepare documents and navigate the application process at no cost.
The Social Security Administration typically processes Extra Help applications within 30 days. If you apply online, you may receive a faster response. Once approved, your benefit usually begins the first day of the month following your approval. If you're auto-enrolled through Medicaid or SSI, enrollment is typically immediate with no separate application required.
Yes. Extra Help works with Medicare Advantage Prescription Drug plans (MA-PD) as well as standalone Part D plans. If you have Extra Help and enroll in a Medicare Advantage plan with drug coverage, your drug cost-sharing is reduced the same way it is with a standalone Part D plan. Robert Simm can help you find Medicare Advantage plans in Durham County that are optimized for Extra Help recipients.
The Social Security Administration conducts an annual redetermination of Extra Help status. If your income rises above 150% of the Federal Poverty Level, you may lose full Extra Help and receive partial Extra Help or no benefit. You will receive a notice and have 60 days to appeal. If you receive Medicaid or SSI, changes to those programs may also affect your deemed Extra Help status. Robert Simm tracks annual redeterminations for all Durham County clients.
Yes — in a very beneficial way. Extra Help recipients receive a Special Enrollment Period (SEP) that allows them to switch Medicare Part D or Medicare Advantage drug plans once per calendar month, throughout the year. This means you are not locked into Open Enrollment periods and can change plans any time your needs change, a new drug is prescribed, or a better plan becomes available in Durham County.
Extra Help reduces your cost-sharing for all drugs covered under your Medicare Part D plan's formulary. It does not expand the list of drugs covered — it simply lowers what you pay for covered drugs. This is why it's essential to choose a Part D plan whose formulary includes your specific medications at preferred tiers. Robert Simm compares formularies for every Durham County client to ensure Extra Help delivers maximum real-world savings.
It is never too late to apply for Extra Help. You can apply at any time during the year, and there is no age restriction beyond being enrolled in Medicare Part A and/or Part B. If you were eligible in prior years and did not receive the benefit, you cannot receive retroactive Extra Help payments — but you can begin saving immediately upon approval. Call Robert Simm at (828) 761-3326 for a same-day eligibility check.
Extra Help copays are standardized ($4.50 generic / $11.20 brand-name for full benefit recipients in 2026), but they apply only at pharmacies in your Part D plan's network. Using an out-of-network pharmacy may result in higher costs or no coverage. Robert Simm verifies that recommended plans include major pharmacy networks in Durham County — including major chains and local independent pharmacies — so your Extra Help copays apply where you shop.
“One call. 20 minutes. You leave knowing exactly what to do.”
I pull every plan available in your county. Verify your doctors are in-network. Price your medications. Show you the total annual cost side by side — not just the monthly premium. No follow-up calls from strangers. No obligation. Just the full picture, finally.