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Part D

“Extra Help”

…the federalLow Income Subsidy

(LIS) program

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�Help with drug plan costs for people with limited income and resources

�Eligibility determined by SSA or state

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�Some groups are automatically eligible� People with Medicare and

� Full Medicaid or

� Partial Medicaid (MSPs) or

� Supplemental Security Income (SSI)

�Everyone else must apply

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Federal

Poverty Level

Family

Size

Monthly Income 2018

Resources*2018

*(Excludes home, car, and $1500/pp burial plan)

100%

(Full subsidy)

Individual-------------Couple

$1,012-------------

$1,372

$0**-------------

$0**

135%

(Full subsidy)

Individual-------------Couple

$1,366-------------

$1,852

$0**-------------

$0**

135%-150%

“Level 4”

Individual-------------Couple

�$1,518-------------�$2,058

$14,100-------------$28,150

**Resources are no longer counted for MSP eligibility. Those qualifying for MSP are deemed eligible for LIS.

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� Countable income includes:� Social Security benefits (e.g., retirement, SSI),

Railroad Retirement benefits

� Pensions or annuities, including veteran’s pensions

� Wages (gross) or earnings from self-employment (net)

� Alimony

� Rental income (net)

� Excluded income includes:� SNAP (Food Stamps) and LIHEAP (fuel assistance)

benefits

� Work-related expenses for people who get Social Security benefits for a disability or blindness

� Get full breakdown at:https://www.ncoa.org/resources/part-d-extra-help-cheat-sheet/

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� Countable resources include:

� Financial institution accounts (e.g., checking, savings, CDs)

� Cash at home

� Stocks, bonds, savings bonds, mutual funds, individual retirement

accounts (IRAs), and 401(k) accounts

� Real estate (equity value) other than primary home

� Certain trusts that allow a person to revoke or have direct use of funds

� Excluded resources include:

� Home in which the applicant lives

� All vehicles (autos, trucks, motorcycles, boats, snowmobiles, etc.)

� Household goods/furnishings, and personal effects (e.g., jewelry)

� Cash surrender value of life insurance policies

� In-kind support (e.g., non-cash help such as shelter)

� Irrevocable burial trusts/burial contracts

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�With Level 1, 2 or 3 subsidy and an LIS-compatible (benchmark) plan, then:� $0 premium

� $0 deductible

� No coverage gap (“donut hole”)

� Co-pays at pharmacy of $1.25 / $3.70

or $3.35/ $8.35 (2018)

� Must be enrolled in a plan (MAPD or PDP)

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�Income up to 150% of FPL allowed

�Sliding-scale premium� 25%-100% subsidy

�$83 deductible (2018)

�15% pharmacy copays

�Coverage GAP requires 15% copays

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�Premium - Sliding scale premium depends on income percentage of FPL

Income

Percent of FPL

Premium Subsidy

<135% 100%

>135% - <140% 75%

>140% - <145% 50%

>145% - <150% 25%

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Scenario: Client has an income of 135% of FPL with Level 4 LIS and takes Spiriva Handihaler. Symphonix Value Rx is the least costly plan, retail. Full cost is $420.13

Plan Benefit LIS Benefit

Premium $28.10 $0.00 (100% subsidy)

Deductible$405

$83.00(Maximum)Plus 15% up to plan deductible

Initial Benefit $29*/$39 $64.36 (15% of Rx cost)

Coverage Gap $150.16 (35% of Rx cost) $64.36 (15% of Rx cost)

*Preferred Pharmacy/Non-Preferred Pharmacy

Consumer always gets the benefit of the lower cost –either the plan benefit or the subsidy benefit.

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$43.32 in Stage 2, Initial Coverage Period

$131.50 in Stage 1, deductible

$63.02 in Stage 3 Coverage Gap

$29/mo in Stage 2 once deductible is met at Preferred Pharmacy

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� Anyone with any level

of LIS has a continuous

SEP for starting,

stopping, or switching

PDP or MAPD plans!

� …and no penalty for

late enrollment!

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� Temporary PDP for all LIS-eligible

� Covers those approved but not yet in a plan

� Covers those in-between plans

� Up to 2 months, begins 1st day of application month

� All Part D drugs, no restrictions

� Similar benefit as if in a plan (depends on pharmacy)

� Administered by Humana

� SHIP Hotline # 1-866-934-2019

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�www.BenefitsCheckUp.org/Oregon

�Application takes 10 minutes to complete

�No documentation required

�SSA will verify with IRS, financial institutions, etc.

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�If unable to complete application during counseling appointment due to

� Out of time

� No internet

� Personal preference

�Refer beneficiary to Oregon Medicare Savings Connect 855-447-0155

�Refer beneficiary to State office 800-722-4134

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� OMSC is intended to assist� Clients calling directly for application processing

� Counselors wanting to verify client benefit level

� Complex SHIBA questions or appeals go to your SHIBA coordinator or State SHIBA

� See Patient Assistance Resources handout for other ways to help clients

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BenefitsCheckUp.org/Oregon

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BenefitsCheckUp.org/

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Scroll to bottom of page

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Scroll to bottom of page

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Anytime you are unclear about the question, you can

click on the HELP link

If you answer YES to question 1, you will need to include your

information on the next screen

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This question is NO unless someone in on Medicare

due to disability

If you answer YES to question 9, the applicant is

not eligible for subsidy.

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Question 13 is the Completer’s address

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For quickest service, FAX LIS

application or refer client to

local APD office rather than

through this option.

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This question is confusing to many, so I usually just ask if they have pre-paid for their burial plans instead

These can be reasonable estimate

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Read this statement in its entirety

Check each box as signature

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Confirmation will only show the last four digits of SSN.

When FAXing to an APD office, you will need to write the

whole SSN on the document.

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IMPORTANT

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� Fax or phone the appropriate APD office with the client’s information (i.e. LIS application) to refer for QMB eligibility

� On the client contact form:

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If you call or fax

information to the APD

office for MSP

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If you helped with both LIS and MSP, then mark a “3” in the MIPPA field

Once you’ve screened (or client has self-screened)income and resources, record that on the CCF:

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� Also record that you have screened for LIS and MSP – because you have.

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Remember the “opt out” box?

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� DHS/APD Branches get the information from Social Security every month.

� They send letters inviting the person to apply for more benefits.

� MIPPA Grant staff follow up 30 days later with those who seem eligible but have not applied, to see if we can assist. If so, we start an application by phone and send it to the local branch.

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� LIS Applications usually take 10-15 minutes once you become familiar with the process

� Can print out the lengthy pages to avoid reading

� Client will receive notice from SSA usually within 30 days of submission

� MSP Eligibility is determined by APD and can take up to 45 days after all documents are submitted

� If client already has a Part D plan, benefits are applied retroactively to the first day of the month application was submitted

� If client does not have a Part D, they can join a plan

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Happy

Valentines

Day!