Background on Limited-Income Subsidy Deeming

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for a portion of drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

The limited-income subsidy (LIS) is Extra Help for people with Medicare who have limited income and resources to help pay their Medicare prescription drug plan costs (plan monthly premiums, copayments and the annual deductible). Certain groups of Medicare beneficiaries are automatically deemed eligible for LIS.

These groups include:

• Full benefit dual eligible individuals
• Partial dual eligible individuals (i.e., those who belong to a Medicare Savings Program as a Qualified Medicare Beneficiary, Specified Limited-Income Medicare Beneficiary or Qualifying Individual)
• And people who receive Supplemental Security Income (SSI) benefits but not Medicaid

Other individuals with limited incomes and resources who do not automatically qualify can apply for a limited income subsidy and have their eligibility determined by either the Social Security Administration (SSA) or their State Medicaid Agency. Table 1 provides an overview of how people qualify for LIS.

Table 1. Overview of how people qualify for LIS
To qualify for extra help, you must meet at least one condition in each column:

Medicare Part A or B	U.S. residency	Income and assets
You are entitled to Medicare Part A (Hospital Insurance). OR You are enrolled in Medicare Part B (Medical Insurance).	You live within the plans service area.1	You are single and have income of less than $16,245 and resources of less than $12,510.2 OR You are married and have income of less than $21,855   and resources of less than $25,010.2

¹Programs may vary if you live in the United States Territories (i.e. Puerto Rico and U.S. Virgin Islands).

²These resource limits include $1,500 per person for burial expenses.

Today’s Options^® PFFS understands the needs of Medicare Beneficiaries for the Federal Government’s Limited-income Subsidy. Today’s Options recommends its Today’s Options Value (PFFS) and Today’s Options Value powered by CCRx (PFFS) plans for LIS-eligible beneficiaries.

Background on Best Available Evidence Policy

Best Available Evidence (BAE) policy is used when the limited-income subsidy information in the Centers for Medicare & Medicaid Services’ (CMS) systems is not correct. CMS relies on monthly files from the states and Social Security to establish an individual’s limited-income subsidy deemed eligibility and appropriate cost-sharing level. In certain cases, CMS systems do not reflect a beneficiary’s correct LIS deemed status. This may occur, for example, because a state has been unable to successfully report the beneficiary as Medicaid eligible or is not reporting him/her as institutionalized.

Best Available Evidence is a document that shows you qualify. Once Today’s Options validates the Best Available Evidence with Medicaid/Medicare, we will update your Limited Income Subsidy Assistance status as quickly as possible.

Documents that show you qualify are listed. Please print the checklist, and mark the documents you send (include the checklist as well).

You may fax copies of your Best Available Evidence along with the checklist to us at 1-440-287-9798.  Or you can mail it to us at:

• P.O. Box 740968
  Houston, TX 77274-0968

For more information on Low income subsidy and BAE, you may visit the BAE policy on the Medicare Web site.