Medicare, Medicaid, and Low-Income Subsidy can benefit those with low-income or few assets. Qualifying for both Medicare and Medicaid means the beneficiary is dual-eligible.
Beneficiaries can apply for the Medicaid program through their states Medicaid office. If you’re eligible for Medicaid, eligibility for Low-income Subsidy (LIS) is automatic.
If you’re not eligible for Medicaid, you may still be eligible for LIS.
Medicaid and Medicare Dual-Eligible
Many people confuse these two coverage plans, Medicare and Medicaid. However, Medicare is for those over 65 or with long-term disability. Whereas Medicaid is for those with low income and few resources.
Beneficiaries eligible for both Medicare and Medicaid are Dual Eligible. Although, if you’re not Medicaid eligible, you may still qualify for LIS.
Medicaid and Medicare Enrollment Help
Beneficiaries can enroll in Medicaid through the state program office. This can be done online or in-person.
Medicare applications are done through Social Security. Applications are available online at the Social Security Administration website. However, other options are available for applying.
You can apply over the phone with Social Security, in person, or by mail.
Once you’re eligible for Medicare and Medicaid you become “Dual Eligible”.
Dual Eligible Medicare
If you qualify for Medicaid, you receive automatic enrollment in LIS. Medicaid benefits include coverage for copayments and coinsurance that Medicare doesn’t pay.
Medicare is the primary insurance and Medicaid is secondary. Purchasing a Part D Plan is a requirement; although, not selecting a policy could result in Medicaid selecting a policy for you.
Generally, LIS covers the Part D premium and Medicaid covers the medical expenses left by Medicare.
How Often Can Dual Eligible Beneficiaries Change Plans?
If you have both Medicare & Medicaid, you can change your plan at any time during the year. The effective date of the plan will be the 1st day of the following month.
Effective January 1, 2006 – The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) mandated the Part D Program. Along with the Part D program, is the Medicare Low Income Subsidy (LIS).
This act gave beneficiaries options for prescription drug coverage. The low-income subsidy is extra help.
Extra help is for those with low income and few resources. Beneficiaries may apply for the Low-Income Subsidy (LIS) with their State Medicaid agency or with the Social Security Administration (SSA).
MMA requirements include both the State, and the SSA to accept any LIS applications. Although, certain states have their own eligibility process in place.
After the application process, following acceptance, beneficiaries with LIS get help covering Part D costs. Extra Help benefits include Part D annual deductibles, coinsurances, monthly premiums, and copayments.
Additionally, low-income subsidy enrollees are exempt from the Medicare “donut hole” or coverage gap.
Medicare Extra Help Qualifications
Some states have different rules on income and resource limits for Medicare Savings Program eligibility. MSP rules the limit of a person’s maximum income to 135% of the Federal Poverty Line.
The maximum resource level for the full low-income subsidy may not exceed $4,000 per person or $6,000 per couple. Qualifying applicants must remain within this resource threshold to be eligible.
That standard in 2009 is $6,600 per person and $9,910 per couple. These numbers do not reflect any burial fund exclusions.
Qualifying beneficiaries for the low-income subsidy must have both assets and income lower than the eligibility limit.
CMS may change the program’s eligibility limit from year to year. They update changes online.
Beneficiaries with income above the eligibility threshold – who provide for other relatives living in the same household.
Otherwise, residents of Hawaii or Alaska may also qualify for low-income subsidy eligibility.
To apply, fill out an “Application for Extra Help with Medicare Prescription Drug Plan Costs” form through Social Security.
Applying for the Low-Income Subsidy
Either SSA or the State Medicaid office will determine low-income subsidy eligibility. Applicants must calculate any assets of theirs, that count towards eligibility.
Insurance policies, vehicles, and primary residence are not assets Medicare counts towards eligibility. Assets may include any income property, mutual funds and IRAs, cash/bank accounts, and stocks/bonds.
Extra Help savings is available to many people who qualify, and they don’t even know it. The easiest way to determine if you qualify is by filing and submitting a LIS application.
Coordinating LIS and MSP Applications
Consumers may find benefits in applying for both low-income subsidy and the Medicare Savings Programs. States must use Federal rules for determining the subsidy application decision.
Meanwhile, the MSP determinations use the State’s rules. Beneficiaries with a Medicare Savings Program, Medicaid or Supplemental Security Income (SSI) automatically qualify for the low-income subsidy.
The Centers for Medicare & Medicaid Services (CMS) sends a purple notice to beneficiaries with information when they don’t need to apply for Extra Help.
LIS Notices and Appeals
In some cases, the SSA may deny a LIS application. Should you disagree with the application decision, you have 2 chances to request a reexamination of your case.
You’ll find a Pre-Decisional Notice prior to the official denial of the application. This notice explains your application’s denial and informs you why you may not be eligible for the program.
After the final decision, applicants receive either a Notice of Denial or a Notice of Award. Applicants may qualify for either full or partial assistance.
It’s better to appeal any decisions you disagree with, rather than reapplying. After appeal approval, assistance begins the 1st day of the month of the application submission.
To file an appeal, beneficiaries must request a hearing within 60 days from receiving the decision notice. Hearings happen 20 days after the request. You can waive this hearing if you want it sooner.
You’ll receive a confirmation notice in the mail, with the date of the hearing. This notice also provides a toll-free number for you to call for further information.
Notices explain how to submit any evidence you have that supports your case. Following the hearing or case review, SSA will send a final decision notice.
If you still disagree with the SSA’s decision, file another appeal in Federal District Court.
Special Enrollment Period for Medicare Dual Eligible
Beneficiaries with Medicaid and Medicare qualify for a Special Enrollment Period (SEP); you can disenroll, join, or switch to a different Part D or Healthcare Plan.
The Special Enrollment Period for LIS/Extra Help begins the month a person is eligible for assistance. The new plan in LIS becomes effective on the first day of the month after enrolling.
If you or someone you love needs Extra Help, consider applying for Medicare’s low-income subsidy.
Dual Eligibility Medicare and Medicaid
If available a Medicare Advantage Special Needs Plan could be beneficial. The SNP could provide further benefits than Original Medicare, such as routine dental, vision, and hearing.
Some SNP plans even include a gym membership program such as silver sneakers.
Income Limits for Extra Help with Medicare Part D
Those single with an income of less than $18,735 annually and resources of Less than $12,890 qualify for Medicare Part D LIS.
Low-income Subsidy will help beneficiaries cover the costs of Part D. Extra Help can help cover the cost of Part D annual deductibles, premiums, and copayments. If you have Extra Help and a Part D late enrollment fee is due, Extra Help waives the fee.
Having coverage is something everyone needs to consider, whether you qualify for extra help or not. Give us a call today and find out about your eligibility.
Those that need help covering the costs of Medicare deductibles, coinsurance, and copayments can call us at the number above. You can also fill out our online rate form to get the process going.