LIS – Low Income Subsidy – Extra Help
What help can I receive if I can’t afford all my Prescriptions?
What if I have too many assets or higher income aka More Assistance?
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
SSA.Gov LIS/Extra Help
What help can I receive?
The Social Security Extra Help is estimated to be worth about $4,000 per year. Publication 10013 * 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.
Here I am today, October 2020 rewriting this page to answer the question below for someone who has too much income & assets to qualify for extra help, what can they do? 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.
- Information on the Extra Help program
- See if you qualify for Extra Help and apply
-
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.
- Some examples where your income may be higher and you can still get Extra Help include if you or your spouse:
- 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
- Extra Help forms and publications
- Extra Help information for caregivers and organizations
- Information on the review of your eligibility
- State Manual 31 page pdf
- Extra Help forms and publications
- Review of Eligibility # 10111
- Matrix Chart for types of eligibility and qualifications
- Extra Help information for caregivers and organizations
Apply ONLINE for Extra Help # 10525
Understanding Part D Extra Help # 10508
Guide to Medicare Rx – Publication 11109 Extra Help Section
Trouble Paying Rx Prescription Drugs # 11318? 3 fold flyer
Information for Native Americans & Alaska Natives # 10013
Prescription Drug #RxGuide
PDF # 11109
*****************
******************
Our webpage on High Income Surcharge IRMAA
Our High Income Surcharge Video Explanation
- 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
- Donut Hole – Coverage Gap
- Rx covered under Part B
- Maximus Appeals LEP Late Enrollment Penalty
- VIDEO How Part D Late Enrollment Penalty is calculated
- Premiums for those with High Income Parts D Rx & B Doctor Visits
- Medicare Rules for High Income People Medicare Costs # 11579
- Shop & Compare Tools Part D Rx
- Get Instant Quotes, Information & Enroll online
Here’s #MoreAassistance
Even if you have high assets & Income
Beyond Part D Rx
Assistance Programs from the Manufacturer
and Government Programs
Medication Assistance Tool.org the Medicine Assistance Tool, matches patients like you with resources and cost-sharing programs that may help lower your out-of-pocket costs, whether or not you have insurance. 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
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
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.
- 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.
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. 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. 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
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.
#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
Response from Anthem Blue Cross CA…
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.
Links & Resources
My Advocate Helps Save money, engage with your community, and improve your health. Take advantage of the different programs in your area. My advocate makes it easy to find programs that fit your life.
CA Health Advocates.org on LIS/Extra Help
Hi Cap Medicare Counseling ca health advocates.org/hicap/
4 Ways to Help Lower your Medicare Prescription Drug Costs # 11417
The Implications Of Rutledge v. PCMA For State Health Care Cost Regulation
https://www.healthaffairs.org/do/10.1377/hblog20201216.909942/full/
give Medicare the power to negotiate for lower drug prices, add new benefits to Medicare
Adding dental, hearing and vision benefits to Medicare.
Making new investments in home and community-based services to “help seniors, persons with disabilities and home care workers,”
Extending a boost to ACA income-based subsidies that were included in the American Rescue Plan Act. The boosted subsidies are set to expire after the 2022 coverage year.
https://www.fiercehealthcare.com/payer/framework-for-3-5t-senate-package-seeks-to-close-medicaid-gap-add-new-medicare-benefits-and
Prior FAQ’s
What if you have $$$ from Sale of Home and are buying a new home?
First, see our General Page on the Low Income Subsidy LIS we will try not to duplicate the same information.
The “Extra Help” part of my disabled wife Linda’s Prescription Drug Plan PDP is a big deal to us.
Not only does it cover the deductible, but the co-pays on Linda’s specialty drugs (Keppra, Lamictal) can be costly, and the extra help wipes this out.
But, I have no idea what allows her to qualify for this, and I’d like to understand how to ensure she gets this benefit in the future?
I have a copy of a letter from Social Security that says they don’t count 1/2 income, but I can’t find a citation for that…
What Income Counts or Not & Assets Cheat Sheet NCOA.org
https://www.ssa.gov/benefits/medicare/prescriptionhelp/
https://cahealthadvocates.org/prescription-drugs/how-to-qualify-for-extra-helplow-income-subsidy-lis-with-part-d-costs/
Eligibility Review # 10111
Disability Benefits 101.org
Guidance to the States on LIS 2009Shop your Part D Plan
https://www.janssencarepath.com/sites/www.janssencarepath.com/files/xarelto-savings-program-overview.pdf
https://www.xarelto-us.com/
XARELTO® is approved by the FDA to help reduce the risk of blood clots in common conditions like atrial fibrillation (AFib), deep vein thrombosis (DVT), and pulmonary embolism (PE). It is also approved to reduce the risk of major cardiovascular events in conditions for which no other anticoagulant has been approved before, such as coronary artery disease (CAD) and peripheral artery disease (PAD).
I just used Medicare’s Rx Shopping Guide and I still have to pay almost $5,000 in premiums and co-pay for my medications for M S Multiple Sclerosis.
What can I do to lower that???
My husband and I earn around $35k and have way too many assets.
Here’s the list of Rx that I take.
Here’s the printout from Medicare.Gov on what the monthly Rx costs are, Donut Hole etc. This was the LOWEST cost plan!!!
https://steveshorr.com/steveshorr/medi_gap_medicare_advantage/pdf_s/10-15-2020-SilverScript%20SmartRx%20%28PDP%29.pdf
We tried entering your Rx at
Medicine Assistance Tool.org
https://medicineassistancetool.org/
and it said their were no programs for you.
Alendronate (Fosamax) slows calcium loss from bones. It helps to make normal healthy bone and to slow bone loss in people with Paget’s disease and osteoporosis. It may be used in others at risk for bone loss. It is more popular than comparable drugs. It is available in generic and brand versions. Generic alendronate is covered by most Medicare and insurance plans, but manufacturer and pharmacy coupons can offset the cost.
The lowest GoodRx price for the most common version of alendronate is around $5.40, 93% off the average retail price of $86.68. https://www.goodrx.com/alendronate
If I’m reading the Medicare.gov worksheet correctly, the cost for you of Alendronic acid 70 mg is $150 and your cost is $19
Generic Provigil
MODAFINIL is used to treat excessive sleepiness caused by certain sleep disorders. This includes narcolepsy, sleep apnea, and shift work sleep disorder.
The lowest GoodRx price for the most common version of modafinil is around $19.90, 97% off the average retail price of $671.26. https://www.goodrx.com/modafinil
The worksheet from Medicare.gov says Modanil 200mg tablet $482.45 you pay $47
See our other research on expensive Rx like Humira
https://medicare.healthreformquotes.com/part-d-rx/donut-hole/#comment-24970
What about Canadian Pharmacies?
https://www.aarp.org/health/medicare-insurance/info-10-2010/online_pharmacy_fraud.html
LA Times on Trump drug pricing changes….
https://www.latimes.com/business/story/2020-08-27/david-lazarus-prescription-drug-prices