Medicaid Levels/ Extra Help/ LIS


     Levels of Dual Eligibility 
    List  of Medicaid Covered Services
     Medicaid coverage after Medicare
     How Medicaid works with Medicare
     Extra Help LIS


Medicare Savings Programs (MSPs) are Medicaid-administered programs for people on Medicare who have limited income and resources.

These programs help those qualified to afford Medicare.

There are four different Medicare Savings Programs, each with different income and resource eligibility limits. These are the limits for 2022:


     Medicare Savings Programs Eligibility and Coverage Chart

Medicare Savings Plan Levels




QMB and QMB + levels are the only ones with 100%  of the:


       Medicare cost-sharing


Medicaid Spend-Down


Some clients with SLMB status will have a Spend-Down where, during every 6 month period, they will have to accumulate a certain amount in uncovered Medical costs before Medicaid would step in and start covering Medicare cost-sharing. That amount can vary between $200 to as much as $9000 or more.

You can still enroll those clients into the Dual SNP plan, where they will get access to all the extra benefits, zero Family doctor and Specialist visits, and Max -out -of pocket of $6700 (if the Spend Down amount is less than $6700, then Max out of Pocket is The Spend-Down amount)


     Medicare Out-of-Pocket cost


( Original Medicare does not have Max-out-of Pocket)

The rest of the Medical Services (besides Doctor’s office visits ) will still be subject to the Spend Down. Make sure the client knows that! 

That means –

  • Deductible of Part A

  • Deductible of Part B 

  • 20% percent Part B coinsurance

 ( MAPD plan will pay claims  just like Original Medicare would pay them), with exceptions of: 

-$0 copay Family Doctor and -$0 copay Specialist

 -Max- Out-of-Pocket 

You can check on somebody’s

Spend Down amount by

calling PHD or local Medicaid.


     Spend Down


Medicaid eligibility for Medicare beneficiaries who need long-term care in the home or community

Medicare DOES NOT cover long-term care

Medicaid DOES COVER it for some beneficiaries 


      Medicaid eligibility for Medicare beneficiaries who need long-term care in the home or community


Types of Care for Seniors Covered by Medicaid

      Types of Care


!Its normally not recommended to enroll somebody who has


       Integrated Health Care      

Services, such as :


      Health Homes  


Medicaid Dental/Dentures / Vision/Transportation/ benefits per State  


     Medicaid Dental
     Medicaid Dentures
     Medicaid Vision
     Medicaid  Transportation Benefits 


 Medicare / Medicaid  Coverage for Mental Health


      Medicare and Mental Health


Most of the Mental Health needs for people on Medicare/Medicaid are covered by Medicaid


       Medicaid Coverage of Mental Health






LIS (Extra Help)




What is the Medicare Low-Income Subsidy?

Eligible beneficiaries, who have limited income, may qualify for a government program that helps pay for


     Medicare Part D prescription drug costs.


LIS only helps clients with Pard D costs,  NOT  Medicare Cost Sharing or Part A or B premium.

If the client is eligible for LIS – it does not mean that he is ALSO eligible for Medicaid!  LIS and Medicaid are 2 separate and

unrelated assistance programs. 

-LIS is through Social Security and Medicaid is through individual states. 

-If a client Has Some Medicaid Level – he will definitely have LIS.

-Not the same the other way around- a client can be eligible for LIS and not be eligible for Medicaid

It will show you if somebody is JUST LIS or Dual Eligible or Not Enrolled into LIS program. Also, by asking how much the client

pays for Rx, you can get an idea

of LIS status (if $1.25 or $3.75 or any other amount that’s not an even number)- that would usually indicate some LIS status.

If the client does not qualify for LIS then you need to explain how part D works and explain PART D Late Enrollment Penalty if one



     Part D costs  

     Part D LEP Calculator

Since there are different LIS levels (based on income), sometimes the client will get enrolled into the wrong LIS level. You can fix

it by having a client call LIS

program directly Or call the Insurance company that is providing Part D or MAPD for the client.

LIS is governed by the same rules, no matter what state the client lives in. MEDICAID varies widely between different states.

If the client is ONLY eligible for the LIS, then you can enroll him into any MAPD plan. The only exception is – they ARE NOT eligible

for the Dual SNP plan because

it requires some level of Medicaid.

Since LIS will cover MAPD cost up to the individual state’s limit, but NOT any of the Medical cost-sharing – on average, client can

benefit from the enrollment

into an MAPD plan – since his cost for Emergencies, Hospital, Doctor visits will be much more manageable and he will get Max out

Of Pocket (not available under the original Medicare). Also with some plans- dental, vision, etc.

LIS will cover Part D AND MAPD  premium up to certain limit:


     How much premium LIS covers 


  (varies from state to state). 

LIS will lower the cost of prescription drugs:


     LIS Rx drugs copays


LIS Gives you: 



     Special Enrollment Period (SEP)


once per calendar quarter during the first nine months of the year to enroll in a Part D/MAPD  plan or to switch between plans. Same

as Full or Partial Dual

SEP  (You cannot use the Extra Help SEP during the fourth calendar quarter of the year (October through December).

You should use 





 during this time to make Prescription drugs coverage changes).  NO SEP Full Dual/Partial Dual in the last quarter. Everyone needs

to use AEP election period,

unless special circumstances apply: SEP Move, SEP Loss Of Employer Group Plan, etc.

Medicare beneficiaries receiving the low-income subsidy (LIS) get assistance in paying for their

  • Part D monthly premium

  • annual deductible

  • coinsurance

  • copayments.

Also, individuals enrolled in the Extra Help program do not have a gap in prescription drug coverage, also known as the coverage

gap, or the



      Medicare “dougnut hole” (Coverage Gap)


The amount of subsidy depends on the individual’s income compared to the Federal Poverty Level and resource limitations set by

the Social Security Act. 


     LIS  Guidelines


LIS will pay Part D late enrollment Penalties for delayed enrollment into Part D:


     Part D LEP


If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you 



      Automatically qualify for Extra Help 


regardless of whether you meet Extra Help’s eligibility requirements. You should receive a purple-colored notice from the Centers

for Medicare & Medicaid

Services (CMS) informing you that you do not need to:

     Apply for Extra Help



APPLY for LIS online:



     LIS Application


Remember that Extra Help is not a replacement for Part D or a plan on its own: You must still have a Part D plan to receive

Medicare prescription drug coverage

and Extra Help assistance. If you do not choose a plan, you will in most cases be automatically enrolled in one.

LIS will apply to any part D or MAPD plan client chooses to be in. So, by switching a client to MAPD, the client will pay the same

copays for Rx as before.


Medicare Extra Help eligibility


When calculating eligibility for the low-income subsidy, Medicare does not count resources such as your home (or primary

residence); insurance policies; or a car.

Many people qualify for Medicare Extra Help savings and do not know it. The best way to find out if you qualify is to go ahead and




     LIS income guidelines (In our experience, as long as the client’s monthly income is around $1400, there is a good chance the

extra help will be granted)


How to apply for Medicare Extra Help


To apply for the Medicare low-income subsidy, simply fill out an “Application for Extra Help with Medicare Prescription Drug Plan

Costs” (SSA-1020) form with

Social Security. You can apply and submit this form by:


  • Applying online at:

  •  Apply for Extra Help.  (link)

  • Calling Social Security at 1-800-771-1213 (TTY 1-800-325-0778) and requesting an application be mailed to you or applying

  • over the phone. Social Security

  • representatives are available by phone Monday through Friday, from 7 AM to 7 PM.

  • Applying in person at your local Social Security office.

Typically, It will take up to a month or more to get the decision back.  The client will need to submit checking account statements

and all the rest of the financial info.

Also, check to see if your state has a Pharmaceutical Assistance program


     Pharmaceutical Assistance


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