State
Medicaid agencies may use the Extra Help application, which may be a paper
SSA-1020-OCR or i1020. However, if the Medicaid agency chooses to use a non-SSA
application, the agency must process the application, make the subsidy
determination (and subsequent annual redeterminations or appeals), and share
applicable data with CMS directly. CMS shares the appropriate data with SSA.
This is very rare.
The
preferred method of filing for Medicare Part D Extra Help is through our online
application, the i1020. Refer beneficiaries first to the online process at
https://secure.ssa.gov/apps6z/i1020
If a
beneficiary calls and needs help with the Extra Help application or alleges
that he or she did not receive a form but wants to file for Extra Help, 800#
agents should follow Medicare
Prescription Drug Subsidy eligibility and filing instructions.
If a
beneficiary contacts the FO or and requires assistance completing the Extra
Help application or alleges non-receipt of a form and wants to file for Extra
Help, follow the instructions in HI 03010.001 through HI 03010.040.
People
who file an application and establish eligibility for Extra Help may or may not
be enrolled with a PDP or MA-PD. Enrollment is generally effective the month
after the enrollment request is filed with the PDP or MA-PD. (More information
regarding specific enrollment periods and effective dates of coverage is found
in HI 03001.001F.)
Extra
Help beneficiaries who do not enroll with a PDP or an MA-PD are enrolled in a
plan selected by CMS; however, they may choose not to be enrolled. For
information about facilitated enrollment, see HI 03001.010.
Beneficiaries
with questions about enrolling or choosing a PDP or MA-PD should call 1-800-MEDICARE (1-800-633-4227).
The Medicare TTY number is 1-877-486-2048. Refer beneficiaries to their State
Health Insurance Counseling and Assistance Program (SHIP) for assistance in
choosing a PDP or MA-PD. SHIP telephone contact information is on the back of
the “Medicare & You ” handbook or may be accessed by selecting
the State at http://www.medicare.gov/contacts/organization-search-criteria.aspx
.
An
individual can qualify for a full or partial Medicare Part D subsidy depending
on his or her income, resources (and those of the living-with spouse), and
household size. The resources are compared to one of two resource limits for
individuals and couples. A more detailed explanation of resource limits is
in HI 03030.025.
Income is
based on the Federal Poverty Level (FPL), which considers the number of persons
in the household. To determine household size, a relative is considered in the
same household as the beneficiary if the relative (by blood, marriage, or
adoption) receives at least one-half support from the beneficiary or the
living-with spouse. For more information about income and the FPL see HI 03020.055 and HI 03001.020C.
NOTE: When
discussing Extra Help, it is important to remember that a person who receives a
100% premium subsidy is not necessarily “full subsidy eligible.” A person who
fails to meet the lower resource standards may receive a 100% premium subsidy
but may pay an annual deductible and higher copayments than a “full subsidy
eligible” individual.
2020
resources standards chart for individuals/couples
|
|
With Burial Exclusion
|
Without Burial Exclusion
|
|
Lower Resources Level
|
$9,360/$14,800
|
$7,860/$11,800
|
|
Higher Resources Level
|
$14,610/$29,160
|
$13,110/$26,160
|
NOTE: For
purposes of determining countable resources for Medicare Part D Extra Help
subsidy eligibility $1,500 is excluded from an applicant’s countable resources
if the applicant alleges that he or she expects to use some of his or her
resources for funeral or burial expenses. For a married couple who live
together, we exclude up to $3,000 ($1,500 for each member who alleges he or she
expects to use some of his or her resources for funeral or burial expenses).
For more information about resource exclusions see HI 03030.020.
The charts below explain
the basic Part D benefit and the Extra Help available in 2020 and 2019 for each
subsidy level and for non-institutional deemed eligibles. All resource limits
shown include the $1,500 per person burial exclusion.
1. a. For
individuals/couples at 150% FPL or above, or with countable resources greater
than $14,610/$29,160 or both (basic benefit)
|
If income is
|
150% FPL or above
|
|
And resources are
|
NONE to greater than resource
limit for the year
|
|
The deductible is
|
$435
|
|
The copayment is
|
After deductible, 25% up to $4,020
in out-of-pocket drug cost
|
|
The coverage gap is
|
The beneficiary is responsible for
25% of out-of-pocket costs of brand-name drugs and 37% of out-of-pocket costs
of generic drugs between $4,020 and $9,038.75. The beneficiary’s cost will
continue to decrease each year until it reaches 25% by 2020 for both
brand-name and generic drugs.
|
|
Catastrophic coverage applies
|
After $6,350 in total
out-of-pocket covered drug costs are paid by the beneficiary (usually
representing $9,038.75 in covered drugs), copayments of $3.60 for
generic/preferred, and $8.95 for other covered medications.
|
2. b. For
individuals/couples not eligible for Medicaid, but between 136% and 149% of FPL
(Low-Income Subsidy)
|
If income is
|
Between 136% and 149% FPL
o • 25% premium subsidy from 146-149%
o • 50% premium subsidy from 141-145%
o • 75% premium subsidy from 136-140%
|
|
And resources are
|
$14,610 or less for individuals,
$29,160 or less for couples
|
|
The deductible is
|
$89
|
|
The copayment will be
|
After deductible, 15% up to $6,350
in out-of-pocket drug costs
|
|
The coverage gap is
|
Covered – If the beneficiary is
receiving Extra Help there is no coverage gap
|
|
Catastrophic coverage will apply
|
After $6,350 in out-of-pocket
covered drug costs paid by beneficiary, copays of $3.60 for generic/preferred
and $8.95 for other covered medications
|
3. c. For
individuals/couples not eligible for Medicaid, but less than or equal to 135%
of FPL (Low Income Subsidy)
|
If income is
|
Less than or equal to 135% FPL
with higher resources level
|
Less than or equal to 135% FPL
with lower resources level
|
|
And resources are
|
Greater than $9,360, but do not
exceed $14,610 for individuals
Greater than $14,800, but do not
exceed $29,160 for couples
|
$9,360 for individuals,
$14,800 for couples
|
|
The deductible is
|
$89
|
NONE
|
|
The copayment will be
|
After deductible, 15% up to $6,350
in out-of-pocket drug costs
|
$3.60 for generic/preferred and
$8.95 for other medications
|
|
The coverage gap is
|
Covered – If the beneficiary is
receiving Extra Help there is no coverage gap
|
N/A
|
|
Catastrophic coverage will apply
|
After $6,350 in out-of-pocket
covered drug costs are paid by the beneficiary, and copays of $3.60 for
generic/preferred and $8.95 for other covered medications
|
N/A
|
4. d. For
non-institutionalized individuals deemed eligible for Extra Help
|
If income is
|
Over 100% FPL
|
Up to and including 100% FPL and
full Medicaid eligible
|
|
And resources are
|
Limited by the rules of the
qualifying program
|
Limited by the rules of the
qualifying program
|
|
The deductible is
|
NONE
|
NONE
|
|
The copayment is
|
$3.60 for generic/preferred and
$8.95 for other covered
medications
|
$1.30 for generic/preferred and
$3.90 for other covered medication
|
|
The coverage gap is
|
N/A
|
N/A
|
|
Catastrophic coverage is
|
N/A
|
N/A
|
1. a. For
individuals/couples at 150% FPL or above, or with countable resources greater
than $14,390/$28,720 or both (basic benefit)
|
If income is
|
|
150% FPL or above
|
|
And resources are
|
|
NONE to greater than resource
limit for the year
|
|
The deductible is
|
|
$415
|
|
The copayment is
|
|
After deductible, 25% up to $3,820
in out-of-pocket drug cost
|
|
The coverage gap is
|
|
The beneficiary is responsible for
25% of out-of-pocket costs of brand-name drugs and 37% of out-of-pocket costs
of generic drugs between $3,820 and $7,653.75. The beneficiary’s cost will
continue to decrease each year until it reaches 25% by 2020 for both
brand-name and generic drugs.
|
|
Catastrophic coverage applies
|
|
After $5,100 in total
out-of-pocket covered drug costs are paid by the beneficiary (usually
representing $7,653.75 in covered drugs), copayments of $3.40 for
generic/preferred, and $8.50 for other covered medications.
|
2. b. For
individuals/couples not eligible for Medicaid, but between 136% and 149% of FPL
(Low-Income Subsidy)
|
If income is
|
Between 136% and 149% FPL
o
• 25%
premium subsidy from 146-149%
o
• 50%
premium subsidy from 141-145%
o
• 75%
premium subsidy from 136-140%
|
|
And resources are
|
$14,390 or less for individuals,
$28,720 or less for couples
|
|
The deductible is
|
$85
|
|
The copayment will be
|
After deductible, 15% up to $5,100
in out-of-pocket drug costs
|
|
The coverage gap is
|
Covered – If the beneficiary is
receiving Extra Help there is no coverage gap
|
|
Catastrophic coverage will apply
|
After $5,100 in out-of-pocket
covered drug costs paid by beneficiary, copays of $3.40 for generic/preferred
and $8.50 for other covered medications
|
3. c. For
individuals/couples not eligible for Medicaid, but less than or equal to 135%
of FPL (Low Income Subsidy)
|
If income is
|
Less than or equal to 135% FPL
with higher resources level
|
Less than or equal to 135% FPL
with lower resources level
|
|
And resources are
|
Greater than $9,230, but do not
exceed $14,390 for individuals
Greater than $14,600, but do not
exceed $28,720 for couples
|
$9,230 for individuals,
$14,600 for couples
|
|
The deductible is
|
$85
|
NONE
|
|
The copayment will be
|
After deductible, 15% up to $5,100
in out-of-pocket drug costs
|
$3.40 for generic/preferred and
$8.50 for other medications
|
|
The coverage gap is
|
Covered – If the beneficiary is
receiving Extra Help there is no coverage gap
|
N/A
|
|
Catastrophic coverage will apply
|
After $5,100 in out-of-pocket
covered drug costs are paid by the beneficiary, and copays of $3.40 for
generic/preferred and $8.50 for other covered medications
|
N/A
|
4. d. For
non-institutionalized individuals deemed eligible for Extra Help
|
If income is
|
Over 100% FPL
|
Up to and including 100% FPL and
full Medicaid eligible
|
|
And resources are
|
Limited by the rules of the
qualifying program
|
Limited by the rules of the
qualifying program
|
|
The deductible is
|
NONE
|
NONE
|
|
The copayment is
|
$3.40 for generic/preferred and
$8.50 for other covered
medications
|
$1.25 for generic/preferred and
$3.80 for other covered medication
|
|
The coverage gap is
|
N/A
|
N/A
|
|
Catastrophic coverage is
|
N/A
|
N/A
|
HI 00815.023,
Medicare Savings Programs Income Limits
HI
00815.025, SSA Outreach to Low-Income Medicare Beneficiaries – Extra Help
and Medicare Savings Programs
HI
03001.001F., Description of the Medicare Part D Prescription Drug Program
HI
03001.010, Facilitated Enrollment and Special Enrollment Period for
Individuals Eligible for Extra Help (Low Income Subsidy)
HI
03010.010, Filing Applications
HI
03030.020, Resource Exclusions
HI
03010.035B.1., General Information about the Subsidy Application
HI 03010.039, Exception Processing
HI
03020.055, Income Limits for Subsidy Eligibility
HI
03030.025, Resource Limits for Subsidy Eligibility
HI
03035.005, Verification Policy within the Medicare Application Processing
System (MAPS);
HI
03035.006, Verification and Documentation Process for Medicare Application
Processing System (MAPS);
HI
03035.007, Verification and Documentation Instructions for Internal Revenue
Service (IRS) data within the Medicare Application Processing System (MAPS);
HI
03035.008, Chart of IRS Transaction Types Used for Verification
HI 03040.001,
Overview of Appeal Process for Medicare Part D Subsidy Determination
HI 03050.011, Redetermination of Eligibility
MSOM INTRANETMAPS 005.001 through MSOM INTRANETMAPS 005.013, MAPS
Application Screens
TC 24020.020, Medicare Prescription Drug Subsidy Eligibility and
Filing
|
HI
03001.005 - Medicare Part D Extra Help (Low-Income Subsidy or LIS) -
03/25/2019
Batch run: 01/02/2020 Rev:03/25/2019 |
No comments:
Post a Comment