medicare part d extra help lis

Medicare Part D Low Income Subsidy (LIS) / Extra Help

  • Prescription drug costs can be overwhelming for many Medicare beneficiaries, especially seniors living on fixed incomes.
  • The Medicare Part D Low Income Subsidy program, commonly called Extra Help, was created to reduce the cost of Medicare prescription drug coverage for people who qualify.
  • This program may help pay for Medicare Part D premiums, deductibles, copays, coinsurance, and even reduce or eliminate late enrollment penalties.
  • Many people qualify automatically through Medi-Cal or other assistance programs, while others may qualify by applying directly through Social Security.
 

How and Where to Apply for Extra Help

The primary application for Medicare Part D Extra Help is handled through Social Security. Even if someone thinks they may not qualify, it is often worth checking because the income and resource limits change periodically.


Apply for Medicare Extra Help


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Medi-Medi & Low Income Medicare Help

 

What Does Extra Help Pay For?

  • Medicare Part D monthly premiums
  • Prescription drug deductibles
  • Copayments and coinsurance
  • Late enrollment penalties
  • Some catastrophic prescription drug costs

In some situations, beneficiaries may pay little or nothing for covered prescriptions. However, each Part D plan still has its own formulary, pharmacy network, and prior authorization rules.

The Good: Why Extra Help Can Be Valuable

  • Lower out-of-pocket prescription drug expenses
  • Reduced or zero Part D premiums
  • Special Enrollment Periods allowing plan changes outside the normal enrollment window
  • Protection against very high medication expenses
  • Reduced financial pressure for seniors on fixed incomes
  • Possible help for people who did not enroll in Part D on time and have a penalty

The Bad: What Extra Help Does Not Fix

  • It does not mean every drug is automatically covered
  • It does not eliminate formulary rules
  • Some medications may still require prior authorization
  • Step therapy and quantity limits may still apply
  • Preferred pharmacy networks can still affect costs
  • Plan changes can still be confusing

One common misunderstanding is that “Extra Help” means every medication is automatically free or covered without restrictions. Formularies, network pharmacies, quantity limits, and utilization management rules may still apply.

The Confusing Part:
Extra Help, Medi-Cal, Medicare Savings Programs, and Part D

Extra Help is related to prescription drug costs, but it is not the same thing as Medi-Cal, Medicare Savings Programs, Medicare Advantage, or Medigap. These programs may overlap, but they are not identical.

A person may need to look at several issues at the same time:

  • Do they have Medicare only?
  • Do they also have Medi-Cal?
  • Do they qualify for a Medicare Savings Program?
  • Are they enrolled in a standalone Part D plan?
  • Are they enrolled in a Medicare Advantage plan that includes drug coverage?
  • Are their medications covered on the plan formulary?

That is why this topic often requires more than simply clicking a quote engine. My quote engine is primarily for Medigap comparisons, not Medicare Advantage plan comparisons. For Medicare Advantage, Medi-Cal coordination, Medi-Medi questions, and Extra Help issues, it is usually better to contact me directly or start with the Medi-Medi information page.


Visit the Medi-Medi Medicare & Medi-Cal Page


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GoodRx and Cash-Pay Discount Programs

In some situations, a cash-pay discount card such as GoodRx may temporarily cost less than using a person’s Medicare Part D plan. However, there are important tradeoffs.

We do not know who they are. We are not endorsing them. This is simply an example of a commonly advertised prescription discount program that some consumers compare against their Medicare Part D copays.

 

Medicare Savings Programs and Medi-Cal

 

Medicare Limited Income Newly Eligible Transition Program

  • Medicare’s LI NET Program was established on January 1, 2010, to provide temporary Part D prescription drug coverage for low-income Medicare beneficiaries not already in a Medicare drug plan.
  • LI NET provides temporary Part D coverage to the following:
    • Full Benefit Dual Eligible and SSI-Only beneficiaries on a retroactive basis, up to 36 months in the past; and
    • Low-Income Subsidy (LIS) Eligible beneficiaries at the pharmacy counter and up to 30 days in the past.
    • Learn more  CMS.gov
 

Part B vs. Part D Drug Confusion

  • Some expensive medications may fall under Medicare Part B instead of Part D depending on how and where the medication is administered. This can become extremely confusing for beneficiaries trying to understand their costs.
  • An example sometimes discussed involves infused antibiotics such as daptomycin. Depending on the circumstances, Medicare Part B, Part D, supplemental insurance, Medicare Advantage rules, or Medi-Cal coordination may all affect coverage differently.

Why This Page Matters

  • At many Medicare agent training meetings, Extra Help and low-income prescription assistance programs are discussed frequently because they can dramatically reduce medication costs for qualifying beneficiaries.
  • Unfortunately, many seniors do not know the program exists, assume they earn too much to qualify, become overwhelmed by the application process, ignore confusing Medicare notices, or do not understand the difference between Part B, Part D, Medi-Cal, Medicare Advantage, Medigap, and Extra Help.

Need Help?

If you have questions about Medicare prescription drug coverage, Medicare Advantage, Medigap, Medi-Cal coordination, Medi-Medi eligibility, or whether you may qualify for Extra Help, feel free to contact Steve Shorr Insurance.  [email protected]


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Medi-Medi Help

  • Here’s #MoreAassistance
    • Even if you have high assets & Income Beyond Part D Rx
    • Assistance Programs from the Manufacturer and Government Programs

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.

Resources

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#Co-Pay Accumulator Programs

When Copay Assistance Backfires on Patients  

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.

Optional Deeper Details Below
The practical explanation is above. The section below includes supporting documents, background material, citations, examples, and technical details for readers who want more.