Posted on May 12, 2022 by Steve Shorr — 1 Comment ↓

LIS – Low Income Subsidy 2022 Chart – Extra Help

Get help paying for your prescriptions

Here’s #MoreAassistance
Even if you have high assets & Income
Beyond Part D Rx

Assistance Programs from the Manufacturer
and Government Programs

This tool includes Merck

CA Health Care Advocates – Resources for Rx Drug Savings

The Patient Access Network (PAN) Foundation is dedicated to helping federally and commercially insured people living with life-threatening, chronic and rare diseases with the out-of-pocket costs for their prescribed medications. Partnering with generous donors, healthcare providers and pharmacies, PAN provides the underinsured population access to the healthcare treatments they need to best manage their conditions and focus on improving their quality of life.

Pharmaceutical Assistance Program

Benefits Checkup.org

National Patient Advocate Foundation

National Organization for Rare Disorders

California Prescription Drug Discount Program
At Medi-Cal participating pharmacies, you can get prescription drugs at the Medi-Cal rate plus a $0.15 processing fee. This rate may be lower than the Part D rate. Payments may not apply toward your Part D cost-sharing. This program should not be used as a substitute for Medicare Part D. To receive benefits, show your Medicare card at Medi-Cal participating pharmacies ^{SB 393 2000}

6 Hints to get help with Rx costs on Medicare.gov

california rx card.com

Glaxo Smith Kline Rx Assistance

pfizer rx pathways.com Find Assistance That’s Right for You Pfizer RxPathways connects eligible patients to a range of assistance programs that offer insurance support, co-pay help,^* and medicines for free or at a savings.^†Enter the name of the medicine you’ve been prescribed. You can search one medicine at a time. Then answer a few questions to see which available program(s) may be right for you.

Humira

MS Multiple Sclerosis

Financial Assistance Programs

The Assistance Fund 877-245-4412
GoodDays 877-968-7233
HealthWell Foundation 800-675-8416 *Medicare only
copaxone.com/shared-solutions
RxAssist.org RxAssist can help you learn about ways to use pharmaceutical company programs and other resources to help reduce your medication costs. Look at our database and frequently asked questions to get started.

Manufactures Coupons

If one has Part D Rx, the manufacturers cannot help out with coupons. One might consider dropping Part D or if you have Medicare Advantage Plan, finding one that doesn’t include Part D.
- We CANNOT advise you to do this. It’s beyond our pay grade and we are mandated to tell you about the penalty if you don’t purchase Part D. I’m having trouble finding a reliable plain English citation for this. Scroll down for hints from one of our wholesalers on using coupons and not using your Part D Rx plan.
The intention for coupons is to steer patients away from cheaper generic alternatives and toward the brands that they produce. That is to increase demand for their drugs. Experts estimate that brand drug manufacturers are spending between $3 billion and $6 billion annually on coupon programs. Anti-Kick Back and all. ^{HHS Report} Mfg safeguards might not prevent coupons for Part D Rx. Legally, the use of drug co-pay cards and coupons by individuals with government funded health care and prescription drug benefits, such as Medicare and Medicaid, is prohibited by the federal anti-kickback statute.
- (2) Whoever knowingly and willfully offers or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person—
  - (A) to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or SSA.gov

Resources, Links, Bibliography

Here’s some hints from our wholesaler…

Coupons are allowed to be used in Medicare, but it is tricky. When a client uses a coupon, or a GoodRX or even the pharmacies billing costs (which are sometimes cheaper than the plan copay) the drug doesn’t get run through Medicare, it becomes a cash pay situation and it doesn’t go against the Medicare deductibles, donut hole, etc. So that is the negative.

I have many clients that have purchased drugs directly from the pharmacy to get a lower cost, and some that have used Good RX or even just googled their drugs and bought them online at a cheaper cost.

There are certain things that are much cheaper online, Progesterone is a big one that my female clients find cheaper online..

So, if the pharmacy will work with the client to help them find the lowest cost, there are alternatives for our Medicare clients. Not all pharmacies will do this however, so it is good to do some research on more expensive drugs to find alternative solutions.

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan. MAPD Plans must cover all A & B services ^Medicare.Gov *

That's why the premium is very low or ZERO!

Set a phone or Skype Meeting
#Intake Form - We can better prepare for the meeting
HMO - Narrow Networks?
Do I just sign up with a Medicare Advantage Company and automatically get * Parts A & B or do I have to get those from Medicare.Gov * VIDEO
17 Reasons to use Steve Shorr Insurance
Get Quotes, Full Information and Enroll
MANDATED wording!: ^{Think Advisor} * ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’
We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!
FYI a 4.27.2022 HHS Office of the Inspector General report found that MAPD plans denied 13% of prior authorizations that would have been covered under original Medicare (Conversely, Medi Gap, just follows what Medicare pays.)
88% of MAPD enrollees are happy
MAPD plans often include Dental & Part D - Rx Prescriptions and often have NO premiums! How is that possible? The Federal Government pays them around $700/month to handle your medical care. You must continue to pay your Medicare Part B premium of about $170/month. It's best to apply when you turn 65 for the supplement plans or advantage plans, as that's the main "Open Enrollment" period, guaranteed issue for any plan.
Medicare Advantage Plans also have an annual open enrollment now known as AEP Annual Election Period October 7 to December 15th.
Additional Coverage is important as Medical Bills are increasing Seniors Credit Card Debt or leading to possible bankruptcy?

#GoodRx

goodrx.com/discount-card

We do not know who they are. We are not endorsing them. We’ve heard from some of our clients, who are happy with them.

GoodRx said Wednesday its dispute last year with Kroger continues to affect its bottom line.
The company reported a first-quarter net loss of $3.3 million, or 1 cent per share, compared with net income of $12.3 million, or 3 cents per share, a year ago. Quarterly revenue totaled $184 million, down 10%. The company’s biggest revenue driver, its prescription transaction business, saw a 13% decline, to $155.5 million this year from $134.9 million in 2022.

GoodRx blamed the decline in the prescription transaction business on its contract dispute last year with Kroger, the national grocery chain that temporarily stopped accepting GoodRx’s discounts at the point of sale in May 2022. The company also blamed the Kroger issue for a 5% decrease in monthly active customers from 6.4 million in 2022 to 6.1 million this year. ^{Modern Health Care *}
Los Angeles Times 9.17.2020 Good Rx going IPO - They can make $$$ since the Rx pricing system is so crazy!
Times Rx.com
- On the other hand...
  - No Coupons allowed for Part D Rx
  - They sell your confidential information... LA Times

#Co-Pay Accumulator Programs

If a patient has an insurance plan with an accumulator program, all copays funded by the manufacturer copay savings program will not count towards their deductible and annual maximum out-of-pocket costs. When this patient goes to refill their prescription without the copay savings program, they will be responsible for the full cash price of the drug until they reach their deductible and out-of-pocket annual maximum.

In the absence of accumulator programs, when a patient uses a copay savings program, the portion paid by the manufacturer would contribute to the patient’s deductible. However, copay accumulator programs are designed to keep manufacturer contributions from counting towards a patient’s deductible and annual maximum out-of-pocket costs.

CMS allows all Insurance Plans to do this. ^{Good Rx.com} * ^{Actuary Magazine.org} * ^{Policy Med.com} * ^{ThomsonReuters} *
Los Angeles Times explanation April 2018
Court Ruling in favor of Rx companies: The dispute centers on programs in which drug companies help patients cover their share of the prescription drug costs that they otherwise could not afford.

In recent years, some insurers have established so-called accumulator adjustment programs, in which they do not count assistance toward patients’ deductibles and out-of-pocket maximums. Such programs effectively capture some of the assistance for insurers instead of patients. Read More Reuters.com

Response from Anthem Blue Cross CA…

Our company does use Rx Co Pay Accumulator Programs. Depending on the policy/plan, some Anthem policies do not allow the amounts you save with using a Mfg Rx coupon to count toward your deductible or out of pocket accumulations. Only your true out of pocket expense will be accumulated. If you have any additional questions feel free to contact our Pharmacy Ingenio RX team at 833-419-0530.

Blue Shield of CA

This confirms member’s who use manufacturer coupons for prescriptions, will be credited the amounts paid towards their deductible/out-of-pocket.

Oscar

At this time, the only amount that will contribute towards the members deductible and/or out of pocket maximums will be the amount that the member pays.

Pamphlets, Brochures & Websites to help prevent Fraud

Protect yourself from Medicare Fraud Publication # 10111
Prevent Fraud Publication # 11491
Medicare Learning Network Prevent, Detect & Report Fraud & Abuse
California Department of Insurance on Fraud
New MD’s – how to avoid Medicare & Medicaid – Medi Cal Fraud and Abuse
Doctor who performed unneeded procedures guilty in $12-million Medicare fraud scheme ^{Los Angeles Times}
CMS will be able to revoke healthcare providers or suppliers’ Medicare enrollment if they are affiliated with targeted “bad actors,” a final rule issued Wednesday established.
As part of the CMS’ “Program Integrity Enhancements to the Provider Enrollment Process” going into effect Nov. 4, its new “affiliations” provision allows authorities to bar individuals and organizations that “pose an undue risk of fraud, waste or abuse based on their relationships with other sanctioned entities.” ^{Modern Health Care} *

YouTube VIDEO's

you tube videos

Low Income Subsidy – Extra Help

The Low-Income Subsidy (LIS) program/extra helps pay for a portion of Part D prescription drug plan costs, including Part D premiums, deductibles and copayments.

Depending on your income and assets, you may qualify for the full subsidy or a partial subsidy. All beneficiaries who qualify for the LIS program are permitted to change Part D plans once a month at anytime during the year. ^{CA Health Care Advocates}The full Low-Income Subsidy (LIS) program covers the premium and deductible of benchmark plans, that meet the minimum standards. This means you do not pay a premium or deductible if you receive the full LIS benefit and enroll in a benchmark plan. You are, however, still responsible for copayments of $3.70 to $9.20 for each covered prescription. ^{CA Health Care Advocates}

Ask us a Question? FAQ's?

Apply ONLINE for LIS Low Income Subsidy – Extra Help

Ask us a Question? FAQ's?

SSA.Gov LIS/Extra Help

What help can I receive?

The Social Security Extra Help is estimated to be worth about $5,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income (scroll down to view) and reside in one of the 50 States or the District of Columbia.

Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $4,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.

I feel that the brochure on Medicare Rx Coverage, their extra help section really explains it IMHO the best, simplest and easiest way to understand.

See if you qualify for Extra Help and apply SSA.gov
Qualifications to get Extra Help
- You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
- You live in one of the 50 States or the District of Columbia; and
- Your combined savings, investments, and real estate are not worth more than $29,160, if you are married and living with your spouse, or $14,610 if you are not currently married or not living with your spouse.
  - (Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.)
- Your annual income must be limited to $19,140 for an individual or $25,860 for a married couple living together. Even if your annual income is higher, you may still be able to get some help.
  - Some examples where your income may be higher and you can still get Extra Help include if you or your spouse:
    • Support other family members who live with you.
    • Have earnings from work.
    • Live in Alaska or Hawaii.
- EXCEPTION: If you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid [Medi-Cal] you automatically will get the extra help. ^{Publication 10525} * ^{Social Security ONLINE Application for Extra Help} * ^{Publication 10508 Understand}

National Council on Aging Part D Low Income Subsidy/Extra Help Eligibility and Coverage Chart

What’s on this page?

Extra Help with Medicare Prescription Drug Plan Costs SSA.gov & Apply
Understanding Part D #ExtraHelp10508
Guide to Medicare Rx – Publication 11109 Extra Help Section

Trouble Paying Rx Prescription Drugs # 11318? 3 fold flyer
Janssen – Johnson & Johnson Brochure on Extra Help LIS

Long Term Care Information - Private, Medicare & Medi-Cal?

Prescription Drug 2022 #RxGuide
PDF # 11109

*****************

Coverage Gap - Donut Hole $2,000 Cap

******************

Premiums for those with High Income Parts D Rx & B Doctor Visits
- Medicare Rules for High Income People Medicare Costs # 11579
- Our #High Income Surcharge Video Explanation
- Our webpage on High Income Surcharge IRMAA
- Ways to pay your premium - See page 17
Kaiser Foundation Introduction - Overview
Medicare Rx Benefit Manual Rev 1.2016 83 pages
Network Pharmacies, Formularies & Common Coverage Rules # 11136
Insulin Maximum Co Pay $35
Graphic on Part D Premium Increases & Why?
Maximus Appeals LEP Late Enrollment Penalty
VIDEO How Part D Late Enrollment Penalty is calculated
- Employer Credible Coverage
Shop & Compare Tools Part D Rx
Get Instant Quotes, Information & Enroll online
- Blue Cross
- United Health Care
- Blue Shield
  - scope of appointment
MANDATED wording!: ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’ ^{§ 422.2267(e)(41).}
- We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!

Ask us a Question? FAQ's?

Extra Help with Medicare Prescription Drug Costs

Social Security Handbook

LIS Low Income Subsidy – Extra Help Levels
Income & Assets Charts 2022

Source CMS LIS Memo 10.25.2021
- See Larger & Sharper image
See also Your Guide to Medicare Drug Coverage Extra Help Section

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan. MAPD Plans must cover all A & B services ^Medicare.Gov *

That's why the premium is very low or ZERO!

Set a phone or Skype Meeting
#Intake Form - We can better prepare for the meeting
HMO - Narrow Networks?
Do I just sign up with a Medicare Advantage Company and automatically get * Parts A & B or do I have to get those from Medicare.Gov * VIDEO
17 Reasons to use Steve Shorr Insurance
Get Quotes, Full Information and Enroll
MANDATED wording!: ^{Think Advisor} * ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’
We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!
FYI a 4.27.2022 HHS Office of the Inspector General report found that MAPD plans denied 13% of prior authorizations that would have been covered under original Medicare (Conversely, Medi Gap, just follows what Medicare pays.)
88% of MAPD enrollees are happy
MAPD plans often include Dental & Part D - Rx Prescriptions and often have NO premiums! How is that possible? The Federal Government pays them around $700/month to handle your medical care. You must continue to pay your Medicare Part B premium of about $170/month. It's best to apply when you turn 65 for the supplement plans or advantage plans, as that's the main "Open Enrollment" period, guaranteed issue for any plan.
Medicare Advantage Plans also have an annual open enrollment now known as AEP Annual Election Period October 7 to December 15th.
Additional Coverage is important as Medical Bills are increasing Seniors Credit Card Debt or leading to possible bankruptcy?