More than 2 million people with Medicare qualify for Extra Help, a federal subsidy that slashes prescription drug costs, yet they have never enrolled. That gap, estimated at $11.4 billion in unclaimed annual savings, has persisted for nearly two decades despite repeated federal outreach campaigns and a major expansion of the benefit in January 2024. The people left behind are disproportionately low-income seniors and adults with disabilities who face the highest out-of-pocket drug costs in the Medicare system.
Why the Extra Help enrollment gap keeps growing
The scale of the problem is not new, but its consequences have deepened. The Centers for Medicare and Medicaid Services has stated that more than 2 million people with Medicare may be eligible for the Low Income Subsidy but are not currently enrolled. That same figure appeared in a 2011 Government Accountability Office report, which found that over 2 million beneficiaries were eligible for the LIS in 2009 but did not receive it, attributing the estimate to the Kaiser Family Foundation. The fact that the number has barely moved in over 15 years points to a structural failure in how the federal government connects eligible people to the benefit.
Extra Help covers most of the premiums, deductibles, and copayments that Part D enrollees normally pay out of pocket. Qualifying beneficiaries pay only small fixed copays for generic and brand-name drugs and avoid late-enrollment penalties that can permanently raise premiums. For someone taking multiple medications, the annual savings can reach thousands of dollars. When multiplied across more than 2 million eligible but unenrolled individuals, the aggregate cost of inaction is staggering.
A peer-reviewed study published in PubMed Central examined what happens to low-income Medicare beneficiaries with diabetes who are eligible for the subsidy but do not receive it. The researchers found that those who forgo Extra Help face substantially higher out-of-pocket costs and reduced medication use, outcomes that can accelerate chronic disease complications and drive up emergency care spending. In other words, failing to enroll in the subsidy is not just a financial issue; it is a clinical risk that can shorten lives and increase downstream costs to Medicare and state Medicaid programs.
Broken links between SSA, CMS, and Medicaid redetermination
The enrollment process itself is a central obstacle. The Social Security Administration processes Extra Help applications and automatically “deems” certain groups eligible, including people who receive Medicaid or Supplemental Security Income. SSA publishes detailed application statistics for the program, but those records do not track whether approved applicants actually enroll in a Part D plan. CMS maintains separate Part D enrollment files that include LIS status, yet no public data product links SSA application outcomes to CMS enrollment records at the individual level.
That disconnect matters most during Medicaid redetermination cycles, when states verify whether beneficiaries still qualify for coverage. A person who loses Medicaid may simultaneously lose deemed eligibility for Extra Help without realizing they could apply independently through SSA. Notices are often dense, deadlines short, and options poorly explained. For beneficiaries juggling multiple chronic conditions, limited English proficiency, or cognitive impairment, the odds of navigating this maze successfully are low.
A peer-reviewed analysis using the Medicare Current Beneficiary Survey for 2019 estimated participation rates among community-dwelling eligible beneficiaries and found that a significant share remained unenrolled even among people who clearly met income and asset thresholds. The same analysis noted that Part D low-income subsidies expanded in January 2024, broadening eligibility and increasing the generosity of assistance, but the latest publicly available survey data predate those changes. As a result, researchers and policymakers are effectively flying blind on whether the expansion is closing the gap or simply adding more people to the pool of eligible but unenrolled.
Barriers on the ground
Behind the statistics are practical barriers that advocates have documented for years. Many older adults do not realize that Extra Help is distinct from Medicare Savings Programs or Medicaid, and they may wrongly assume that a previous denial for one benefit means they are ineligible for all. Others are deterred by complex forms that ask detailed questions about assets, or by fears that disclosing financial information could jeopardize other assistance.
Language access and digital divides compound the problem. While online applications have streamlined the process for some, many low-income seniors lack reliable internet access or comfort with web-based forms. Community organizations that provide one-on-one counseling can bridge these gaps, but their reach is uneven and often dependent on short-term grant funding. In rural areas, simply finding an in-person counselor or a public computer can be a major hurdle.
What it would take to close the gap
Experts who study benefit take-up point to several strategies that could shrink the Extra Help enrollment gap. One is to automate eligibility wherever possible, using data already held by federal and state agencies to identify and enroll people without requiring a separate application. Another is to redesign notices and forms using plain language and behavioral insights, making it easier for people to understand what they stand to gain and how to claim it.
Equally important is better data integration between SSA and CMS. Without a clear picture of how many approved applicants successfully end up in a Part D plan with Extra Help attached, it is difficult to target outreach or evaluate which interventions work. Linking administrative records, while safeguarding privacy, would allow for more precise measurement of participation and more timely course corrections.
For now, the persistence of more than 2 million eligible but unenrolled people is a warning sign. It suggests that expanding benefits on paper is not enough; the structure of enrollment, communication, and data-sharing will determine whether those benefits reach the people who need them most.
