Medicaid Levels/ 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 Plan Levels
QMB and QMB + levels are the only ones with 100% of the:
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)
( 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
You can check on somebody’s
Spend Down amount by
calling PHD or local Medicaid.
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
Types of Care for Seniors Covered by Medicaid
!Its normally not recommended to enroll somebody who has
Services, such as :
Medicaid Dental/Dentures / Vision/Transportation/ benefits per State
Medicare / Medicaid Coverage for Mental Health
Most of the Mental Health needs for people on Medicare/Medicaid are covered by Medicaid
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
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
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:
(varies from state to state).
LIS will lower the cost of prescription drugs:
LIS Gives you:
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
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
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 will pay Part D late enrollment Penalties for delayed enrollment into Part D:
If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you
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 LIS online:
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