. Deemed eligible for LIS; copays $3.70 generic, $9.20 brand.Can change Part D and MA-PD plans quarterly. 4 After subtracting $65, only half of work income is counted. Medicare Savings They are administered by Medi-Cal but have different income and asset limits. QMB is important for legal immigrants with 5+ years of residence. Medication and treatment should be a relief, not a burden. Patient Advocate Foundation's Co-Pay Relief program exists to help reduce the financial distress patients, and their families face when paying for treatment. Plan Premium with Full 100% Low Income Subsidy (LIS). (memberships will not roll over from 2020 to 2021 or 2021 to 2022. Memberships will restart on January 1st of.
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MMA Manual
Updated 1/1/21
B. The Low-Income Subsidy (LIS) and copayments
The amount a person pays depends on their income, whether they use generic or brand name drugs, and whether he or she is institutionalized or not. Clients may fall into 3 categories for the Low-Income Subsidy (LIS).Full dual-eligible clients with incomes above 100% of FPL fall into LIS Category 1, paying $3.70 for generic drugs and $9.20 for brand name drugs. Those individuals with incomes at or below 100% of the federal poverty level fall into LIS Category 2 ($1.30/generic & $4.00/brand name). Institutionalized and/or Home and Community based, full-dual clients fall into LIS Category 3, which eliminates copayments.
Medicare Savings Program clients, who do not also have full Medicaid, will always be in LIS Category 1. See the 2021 LIS Reference Sheet.
1. Others with Limited Income
Low Income Subsidy Application 2021
Other Medicare beneficiaries with limited income, including SNAP-only clients, may apply for the Low-Income Subsidy through the Social Security Administration (SSA). They complete the application form by providing their income, resources, and family size. Applications can be completed at www.ssa.gov. If the Social Security Administration determines that an individual is qualified for the extra help, he or she will fall within one of the categories outlined in the 2021 LIS Reference Sheet. The Social Security Administration does not have an Estate Recovery Program for any LIS assistance. If an individual falls within the following guidelines, they should be referred to SSA:
- Annual Income limited to $18,735 for an individual or $25,365 for a married couple living together in 2020 (updated each March).
- Resources limited to $14,610 for an individual or $29,160 for a married couple living together in 2019. Resources include such things as bank accounts, stocks and bonds. We do not count their house and car as resources.
People with Medicare and Medicaid, Medicare Savings Program (MSP) enrollment, or those receiving Supplemental Security Income are automatically eligible for the extra help. People in these programs are “Deemed Eligible”. They do not need to apply for the LIS and do not need to meet the resource limit (as of 2016).
If a person with Medicare loses his or her state medical assistance or MSP eligibility prior to July, he or she will no longer be automatically eligible for the extra help for the next calendar year. The individual must apply for the extra help with the Social Security Administration (SSA) to continue receiving low copayments for their Medicare Part D covered drugs for the following year.
2. LIS Effective Dates
The Low-Income Subsidy is effective the first day of the month of dual eligibility status.
2021 Lis Reference Sheet
Example: A client applies on August 10th, but does not get all of his paper work in until September 5th would have his Medicaid effective on August 10th would have LIS effective retroactively to August 1st.
The exception to this rule is for any client “institutionalized” for MMA purposes. The institutionalized LIS Level 3 is not effective until the 1st of the month in which it is reasonably expected that the dual-eligible client will remain in the facility for a full calendar month, in which Medicaid is paying.
Example: A private pay individual in a facility meets the OSIPM criteria on May 7th and becomes a dual-eligible on that date. The LTC payments begin on that date, as well. It is believed that the client will not be leaving the facility for several months. The LIS level 3 for this client would begin on June 1st.
It is critical that the case is properly coded with the “ISI” case descriptors when it is anticipated that the client will be in a facility for a full month. The “ISI” case descriptor should be removed as soon as the client leaves the facility.
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Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
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