MEDICARE PART D: LET S REVIEW THE LOW INCOME SUBSIDY PROGRAM: February 2010

Transcription

1 MEDICARE PART D: LET S REVIEW THE LOW INCOME SUBSIDY PROGRAM: February 2010 ELIGIBILITY In general, the following groups of people are eligible for Part D low-income subsidies (LIS). o Full Subsidy Eligible Individuals o Full Benefit Dual Eligibles- Beneficiary has both Medicare and a full benefit Medicaid Program. Full benefit Medicaid programs are: Katie Beckett Medicaid. Home and Community Based Waivers Long Term Care (FamilyCare, Partnership, COP) Institutional Medicaid BC+ and BC+ Extensions Standard Plan EBD Medicaid (cat or med needy). BC+ Continuously Eligible Newborn Foster Care Medicaid Adoption Assistance Medicaid Medicaid Met Deductibles Medicaid Purchase Plan ( MAPP ) Wisconsin Well Woman Medicaid SSI -Medicaid o Medicare Savings Programs Beneficiaries QMB: Medicare cost-sharing including Part A premiums, Part B premiums, deductibles and co-payments. Does not cover Medicare Advantage premiums. SLMB/ SLMB+: Part B premiums only o Individuals with income below 135% FPL and resources below $6,600 for an individual/ $9,910 for a couple o Subsidy Eligible Individuals o Income less than 150% FPL and assets below $11,010 for an individual and $22,010 for a couple AVAILABLE BENEFITS

2 Although all individuals who fall into the above categories will be eligible for the lowincome subsidy program, the extent of cost sharing assistance available depends on the following factors: whether the beneficiary receives Medicaid benefits; whether the beneficiary is institutionalized; and the beneficiary s income and assets. 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 25% premium subsidy from % 50% premium subsidy from % And resources are 75% premium subsidy from % $11,010 or less for individuals, The deductible is $63 The copayment will be $22,010 or less for couples After deductible, 15% up to $4,550 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 $4,550 in out-of-pocket covered drug costs paid by beneficiary, copays of $2.50 for generic/preferred and $6.30 for other covered For individuals/couples not eligible for Medicaid, but less than or equal to 135% of FPL (Low Income Subsidy) If income is And resources are The deductible is The copayment will be Less than or equal to 135% FPL with higher resources level Greater than $6,600, but do not exceed $11,010 for individuals Greater than $9,910, but do not exceed $22,010 for couples $63 NONE After deductible, 15% up to $4,550 in out-of-pocket drug costs Less than or equal to 135% FPL with lower resources level $6,600 for individuals, $9,910 for couples $2.50 for generic/preferred and

3 The coverage gap is Catastrophic coverage will apply Covered If the beneficiary is receiving Extra Help there is no coverage gap After $4,550 in out-of-pocket covered drug costs are paid by the beneficiary, and copays of $2.50 for generic/preferred and $6.30 for other covered $2.50 for generic/preferred and $2.50 for generic/preferred and For non-institutionalized individuals* deemed eligible for Extra Help If income is Over 100% FPL full benefit dual eligible with income below 100% FPL And resources are The deductible is The copayment is The coverage gap is Catastrophic coverage is Less than $6,600 for individual and $9,910 for couple NONE $2.50 for generic/preferred and $2.50 for generic/preferred and $2.50 for generic/preferred and N/A Less than $2,000 for a single, $3,000 for a couple NONE $1.10 for generic/preferred and $3.30 for other covered medication $1.10 for generic/preferred and $3.30 for other covered medication N/A $1.10 for generic/preferred and $3.30 for other covered medication N/A Institutionalized full benefit dual eligibles have $0 co-pays after 30 days of institutionalization paid for by Medicaid. APPLICATION METHODS o Medicare beneficiaries interested in applying for the Low-Income Subsidy Program may obtain applications from their local Social Security Administration (SSA) offices. This application can be returned in person or by mail. o Note, the SSA is responsible for administering the Low-Income Subsidy Program (i.e., disseminating applications, determining eligibility, conducting reviews, accepting appeals, etc.); however, SSA will not assist beneficiaries with plan selection or enrollment into the Part D program.

4 o On-line through the SSA website: o Apply for Medicare Savings Program (QMB, SLMB, SLMB+) DEEMING AND DEEMED ELIGIBLE BENEFICIARIES o Deemed Eligible Individuals: Full dual-eligible beneficiaries, Supplemental Security Income (SSI) beneficiaries, and Medicare Savings Program beneficiaries will be deemed eligible for the Low-Income Subsidy Program. These individuals will not need to submit an application. o CMS will mail deemed eligible LIS individuals a letter to inform them that they are eligible for assistance with Part D cost sharing and that they do not need to apply for LIS. The notice is PURPLE and can be viewed here: o In August, CMS begins determining who will be deemed eligible for the upcoming calendar year for the LIS. Redeterminations on a beneficiary s deemed eligible status are normally based on the State s July Medicaid file uploaded to CMS. o Individuals who were previously reported to CMS as LIS eligible in a calendar year and who appear on the July Medicaid file as Medicaid or Medicare Savings Programs eligible will have the end date of their deemed status extended from December 31 of the current calendar year to December 31 of the following calendar year. For example, Sam is on Wisconsin s Medicaid file as of July That information is sent to CMS. Sam will be deemed eligible for all of 2011 and will not have to reapply. o Individuals who were previously unreported by the State to CMS, but who appear on the July file for the first time, will be deemed eligible for the LIS from the first month of dual eligibility (retroactive) to December 31 of the next calendar year. The information sent in the State s July Medicaid file will also be used to establish an individual s subsidy level for the following calendar year. For example, Ron is newly eligible for Medicaid this year but has been Medicare eligible for some time. He appears on the state list as a full benefic dual eligible in a nursing home. His subsidy level will give him $0 co-pays for the rest of this calendar year and all of next calendar year even if he is discharged from the nursing home. If a beneficiary subsequently appears as subsidy-eligible on a State file for the first time between August and December, he or she will also be deemed LIS eligible from the first month of reported dual eligibility through December 31 of the following calendar year.

5 Beneficiaries who received the LIS in the current calendar year, but who do not appear in the July Medicaid file or a later month s Medicaid file as Medicaid or Medicare Savings Program eligible, will not be deemed eligible for the following calendar year. Their deemed status will end on December 31 of the current calendar year. In August, CMS will notify all beneficiaries who are no longer deemed LIS-eligible (based on the States inclusion or exclusion of beneficiaries from their July MMA files). The notice includes instructions and an application for the subsidy. OTHER INFORMATION REGARDING LOW-INCOME SUBSIDY APPLICATIONS A beneficiary s low-income subsidy will be effective the first day of the month of application. Generally, a beneficiary interested in participating in the Low-Income Subsidy (LIS) Program must both apply for the Low-Income Subsidy and enroll in a Part D plan. Either step may be taken first. If a beneficiary applies for LIS after enrolling in a plan, s/he will incur full cost-sharing until the first of the month in which s/he applied for the LIS. Therefore, a beneficiary may want to apply for LIS either before or at the same time as s/he enrolls in a Part D plan to maximize LIS coverage. Individuals who are deemed eligible for the LIS do not need to apply for the LIS. INCOME GUIDELINES: Rules regarding countable and excluded income for the LIS Program are based on the SSI income rules. Income includes anything the applicant (and if married, his or her spouse who is living in the same household) receives that can be used to meet food and shelter needs. For applications filed after January 1, 2010, in-kind support and maintenance (in-kind income) does not count as income for LIS applications. In-kind income is food or shelter or something other than cash that can be used to get food or shelter. The income of the applicant s spouse (if living with the applicant) is counted even if the spouse is not applying for LIS. If an applicant is married, but not living with his or her spouse when an application is filed, only the applicant s income will be counted.

6 When determining eligibility, SSA counts all the income the applicant (and applicant s spouse, if living together) receives or expects to receive for 12 months beginning with the month of application. RESOURCE GUIDELINES: Rules regarding countable and excluded liquid resources for the LIS Program are based on SSI rules. Resources are defined as liquid resources of the applicant (and if married, his or her spouse who is living in the same household) that can be readily converted to cash within 20 days AND the equity value of real estate that is not the applicant s primary resident. For applications filed after January 1, 2010, the cash surrender value of life insurance polices is no longer a countable resource for determining eligibility for the LIS. The resources of the applicant s spouse (if living with the applicant) are counted even if the spouse is not applying for LIS. If an applicant is married, but not living with his or her spouse when an application is filed, only the applicant s income will be counted. When determining eligibility, SSA plans to count resources the applicant (and applicant s spouse, if living together) owns as of the first moment of the month for which eligibility is determined. VERIFICATION SSA will not typically seek verification or documentation of income and assets from LIS applicants. Instead, SSA will conduct computer cross matches with other federal agencies (i.e., IRS). If discrepancies are found, SSA may request documents to verify information. APPEALS The appeals process consists of one level of administrative review. An individual who requests an appeal will have the choice of a telephone hearing or a case review. The time limit for requesting an appeal will be 60 days from the date the applicant receives the notice of determination. SUBSIDY CHANGING EVENTS Unlike most public benefit programs, the low income subsidy eligibility levels are usually determined for the entire calendar year and subsidy beneficiaries are not required to report changes. Subsidy levels will not change during a calendar year unless a

7 beneficiary appeals a subsidy determination, reports a subsidy changing event, or becomes eligible for Medicaid or a Medicare Savings Program. There are six subsidy changing events: Beneficiary marries; Beneficiary and living-with spouse divorce; Beneficiary s living-with spouse dies; Beneficiary and living-with spouse separate; Beneficiary and living-with spouse annul marriage; Beneficiary and previously separated spouse begin living together again. Reports of these changes will result in a redetermination that will become effective the month after the month the change was reported to the Social Security Administration. If SSA receives a report of a subsidy changing event from the beneficiary or any other party, SSA will send a redetermination form to the beneficiary which must be returned within 90 days. Failure to return it within 90 days will result in termination of the subsidy beginning the first month following the 90 day period. For example, Beneficiary gets married in March. Beneficiary calls SSA in April and reports the change. SSA will send her a subsidy redetermination form and will ask Beneficiary if Husband is also on the subsidy. If Husband is also on the subsidy, SSA will send a redetermination form to Husband. Both Beneficiary and Husband will have to complete the redetermination form for a redetermination of eligibility. In this case, Beneficiary reported her own change but she acted as a third party to report Husband s subsidy changing event. It does not matter who reports a subsidy changing event. If their subsidy changing event results in a changed subsidy amount, it will be effective in May. Remember, Beneficiary is not required to report this change but if the subsidy changing event will increase Beneficiary s or Husband s subsidy amount, it is in their interest to report. There is no penalty for failing to report a subsidy changing event. Any other changes in a beneficiary s circumstances are not subsidy changing events and will not change the subsidy level until the following calendar year even if the changes are reported to SSA. Increases or decreases in income or assets will not change the subsidy amount. Reapplication during a calendar year will not change a subsidy amount. For example, Beneficiary and Husband from above example discover buried treasure in their backyard. The treasure chest is full of gold and jewels worth thousands of dollars. Beneficiary and Husband live next to Nosy Neighbor who knows about the treasure. Nosy Neighbor reports the increase in assets to SSA. SSA will send them a redetermination notice sometime between August and December with any changes becoming effective in January of the next calendar year.

8 OTHER LIS MISCELLANEA Ongoing SEP for as long as LIS eligible Use Best Available Evidence Policy if a subsidy eligible individual is being charged incorrect cost-shares at the pharmacy Use LINET for subsidy eligible individuals who do not yet have a Part D plan CMS will continue to enroll subsidy eligible individuals in Part D plans if they fail to enroll themselves or disenroll without opting out of the auto/ facilitated enrollment process Application for LIS serves as an application for MSP with consent of applicant Eligibility for a subsidy will erase a late enrollment penalty even if eligibility for the subsidy is later lost (though if there are subsequent months without creditable drug coverage, those months will be used to calculate a penalty but the plans will not go back to pre-lis months to look for uncovered months.) LIS beneficiaries are not obligated to enroll in a plan with a fully subsidized premium and may enroll in higher cost plans and pay the difference between the subsidy amount and the higher cost plan s premium. For some beneficiaries with many or unusual drugs, this might be more cost effective than enrolling in a plan with a fully subsidized premium. LIS Plans for 2010 with fully subsidized premiums Plan Name Phone Company $0 prem. w/ full LIS AARP MedicareRx Saver Aetna Rx Essentials (800) (888) (800) (877) BravoRx (800) (877) United Health Care Aetna Medicare Bravo Health Insurance Company

9 CIGNA Medicare Rx Plan One Community CCRx Basic First Health Part D -Permier Health Net Orange Option 1 HealthSpring Prescription Drug Plan-Reg 16 PrescribaRx Bronze SilverScript Value (800) (800) (866) (866) (800) (866) for (800) (800) (800) for all (800) (800) (866) (866) CIGNA Medicare Rx Universal American First Health Part D Health Net Orange HealthSpring Prescription Drug Plan Universal American SilverScript Insurance Company