Benefits 101 Series

1. Benefits 101 Series Updated August 2013 Part D Low-Income Subsidy (LIS) Program (also known as “Extra Help”): 102

2. What we’ll cover • Quick Review of LIS/Extra Help • More About the Eligibility Criteria • How LIS Works with Part D • Periodic Review of Eligibility for LIS/Extra Help • Redeeming Process • Redetermination Process • Understanding the Reassignment Process • How You Can Help Your Clients • Resources

3. Snapshot of LIS/Extra Help program • Provides access to prescription drug coverage — helps pay for certain Part D costs, also: • Protects people from Part D Coverage Gap • Waives any late-enrollment penalty premium for Part D • Allows continuous Special Enrollment Period (SEP) • Can start the application process for Medicare Savings Programs (i.e., QMB, SLMB, and QI-1) • CMS and SSA work together to provide this benefit • Most have to apply for LIS (can use paper form or apply online) — some are “deemed” eligible (automatically) get LIS • If eligible, all get LIS for at least remainder of the year

4. What to know about eligibility criteria • Most people must meet financial eligibility criteria: • Income test based on the annual Federal Poverty Levels (FPLs) • Resource (also called “asset”) test • How do these amounts change? • Resource levels usually announced in Dec; income in late Jan • Some people are “deemed” eligible (automatically get LIS) because they receive another needs-based benefit: • People who get any kind of Medicaid (community or institutional), Supplemental Security Income (SSI), or are enrolled in Medicare Savings Program (i.e., QMB, SLMB, QI) • These 3 groups do not need to apply for LIS

5. How does LIS work with Part D? • “Assignment”: When found eligible for LIS, those who do NOT select a Part D plan are randomly assigned (called “facilitated enrollment”) into a Part D plan by CMS that is: • A standard “benchmark” plan (i.e., at or below LIS premium amount) • Plan becomes effective the first day of the next month • This process (“assignment “) does not take into account the individual drug needs of each person • Remember: Anyone with LIS can always change their Part D plan enrollment

6. What about those “deemed” eligible for LIS? • Full Duals (people with both Medicare and Medicaid) are “auto-enrolled” into a Part D plan when first eligible, meaning: • Enrolled in a temporary plan (through LI NET) • Then, randomly assigned (i.e., person’s drug utilization is not taken into consideration) into a “benchmark” plan (i.e., plan has premium low enough so people with full LIS pay no premium) • Those who get SSI or are enrolled in a Medicare Savings Program (i.e., QMB, SLMB, QI-1) get “facilitated enrollment” meaning: • Randomly assigned and enrolled into a benchmark plan • Again, anyone with LIS can always change their Part D plan enrollment

7. More about benchmark plans • “Benchmark” plan means at least LIS premium amount • However, some people may prefer a non-benchmark plan • For example, another plan that may better cover all their drugs • Anyone with LIS can select a Part D plan even if above the benchmark – just means they have to pay the difference in premium

8. Getting continued LIS/Extra Help

9. Does my client with LIS have to reapply each year? • People with LIS generally do NOT need to reapply for LIS each year • Social Security does periodic reviews for continued eligibility • Two ways eligibility for LIS is reviewed for the following year: • Redeeming Process: review of those deemed eligible for LIS • Redetermination Process: review of those who applied for LIS

10. What is the redeeming process? • “Redeeming:” refers to the process of periodic review for those people who have Medicaid, SSI, or are enrolled in a Medicare Savings Program and had been “deemed eligible” for LIS • If Medicaid, SSI, or MSP status remains the same, they get “redeemed” – meaning get LIS for another year • If status changes, person loses “deem” status and LIS benefit for following year • Approximately 1 in 20 lose their “deem” status • IMPORTANT: Those who lose “deem” status should reapply • 50% of those losing status will not get LIS back unless helped by a counselor to reapply for Medicaid, SSI, or MSPs

11. What exactly happens during the redeeming process? • Files are shared: • Starting in July, states send monthly “MMA files” to CMS with info about Medicare beneficiaries currently receiving benefits under Medicaid or one of the Medicare Savings Programs • SSA sends monthly files to CMS with names of people receiving SSI-only • Files are reviewed: • CMS reviews files in August • Those people listed on the files are “redeemed” eligible for LIS for following year • They do not have to reapply — automatically get LIS for the following year • And, they won’t get any notice because their LIS status stays the same

12. Redeeming process (cont.) • Losing Deemed Status: • Those not listed in the August files will lose their deem status for LIS • CMS will send them a letter (called “loss of deemed status” letter) in early fall letting them know that they will no longer automatically receive LIS as of January 1 the following year, and what they can do • Letter is on grey-colored paper (Pub No. 11198) • HOWEVER, just because they receive letter does not mean that they are not eligible for LIS — means they appear to have lost their Medicaid, SSI, or MSP status and consequently their deemed status for LIS: • Letter includes an LIS application and postage paid envelope • Person should reapply for LIS • Also, person should also complete Medicaid application and recertification as appropriate

13. What about those who are “deemed” for LIS after August? • People “deemed” for LIS post-annual review process: • Those not in the August file, but who appear on the files during any month between September and December are “deemed” eligible for LIS through December AND for the following year • They do not need to do anything to maintain their LIS benefits for the following year • CMS will send them a letter (called a “deemed status” letter) in late fall letting them know this • Letter is on purple-colored paper (Pub No. 11166)

14. What is the redetermination process? • “Redetermination”: refers to the process of periodic review for people who got LIS because they applied to Social Security Administration (SSA) – NOT people who were deemed eligible for LIS because they get Medicaid, SSI, or are enrolled in a Medicare Savings Program • SSA is required to periodically “re-determine” these people for continued eligibility for LIS • SSA typically does two types of redeterminations every year: • Initial Redeterminations • Cyclical Redeterminations

15. Initial redeterminations • “Initial Redeterminations”: Affects those who had applied to SSA and were found eligible for LIS between May of previous year and April of current year • SSA screens everyone in this category • Then, SSA selects only a sample for whom a systems data match shows a change in circumstances that may affect their LIS eligibility

16. Initial redeterminations (cont.) • “Redetermination Packet”: SSA mails this packet to those select people (in the fall, usually in Sept), which includes: • Cover letter and a “redetermination” LIS application • Summary including info SSA has on that person’s income, resources, household size, and/or work expenses (for those with disabilities) • Person must complete the paper application (cannot complete online) and return to SSA within 30 days • May request an extension • If do not return application or request extension, then as of March 31 of following year, they will no longer receive LIS

17. Cyclical redeterminations • “Cyclical Redeterminations”: Affects those who had initially applied for LIS and were found eligible for LIS (i.e., not “deemed” eligible) • SSA conducts at least once every 6 years using a profiling system that contains a 350 item-scale of considered risks • Again, SSA screens those selected • As with Initial Redeterminations, anyone who appears to have a change in status receives a “Redetermination Packet” (in the fall) and must complete and return the app within 30 days

18. Possible outcome of redeterminations: change in Help status • Upon completing the Redetermination Packet — or for those who contacted SSA on their own because they experienced a change in status (e.g., income, resources) — they may continue to receive LIS, however there may be a change in their level of help: • Some may get continued eligibility for LIS, but at a different level (e.g., go from full to partial, or from partial to full) • They will get a letter (called “status change” letter) from CMS in the fall letting them know this. • Letter is on orange-colored paper (Pub No. 11199) • IMPORTANT: Your clients should contact SSA if they disagree with this change in status

19. Reassignment process Re

20. What is reassignment? • Plans change year to year: • Some plans leave Medicare market (plan “non-renews” their contract or CMS terminates their contract), or • Plan increases premium – may be above benchmark for following year (i.e., above LIS premium amount) • Protections in place to help avoid lapse in Part D coverage: • Certain people with LIS who were initially “assigned” to these type of plans will be randomly “reassigned” by CMS to another Part D plan to ensure they have some prescription drug coverage come January 1 • IMPORTANT: Reassignment process does not take into consideration a person’s individual needs (e.g., drug utilization)

21. Who gets reassigned? • CMS “reassigns” meaning: • Randomly re-enrolls certain people with LIS into a different stand-alone Prescription Drug Plan (PDP) at the end of the year: • Everyone with LIS in a non-renewing plan is reassigned, and • Certain people with LIS in plans that will be above benchmark • CMS sends them a letter (called a “reassignment” letter) in the fall letting them know this: • Letter is on blue-coloredpaper (Pub No. 11208) • Those being reassigned will get a second notice in early December comparing cost and coverage between current and reassigned plan

22. Exceptions to the reassignment process • “Choosers” (people who selected a plan on their own, or with your assistance, or whose State Pharmacy Assistance Program chose a plan for them when they were first eligible for LIS) are NOT reassigned if their plan will be above benchmark the following year • Instead, they will get a letter from CMS in the fall letting them know they will have to pay a portion of the premium if they stay in the plan • Letter is ontan-colored paper (Pub No. 11267) • However, if their current plan is non-renewing, “choosers” must select a plan on their own by December 31, otherwise they will be reassigned to a new Prescription Drug Plan (PDP) for January 1

23. How you can help

24. Ways to help your clients • Help your clients understand how to get continued LIS – they can always reapply if they disagree with a change in status • Remind your clients with LIS they can change plans or select one on their own – plan should meet their personal financial and health needs • Person-centered approach: Connect your clients with LIS and other benefits (e.g., SNAP, LIHEAP, Medicare Savings Programs)

25. Additional resources • SSA’s electronic fact sheet on Redetermination Process at: http://www.socialsecurity.gov/pubs/10111.html • CMS webpage for resources related to LIS and Reassignment at: https://www.cms.gov/limitedincomeandresources/ • Center for Benefit’s LIS Redeeming, Redeterminations, and Reassignment at: http://www.ncoa.org/assets/files/pdf/center-for-benefits/Extra-Help-Continued-Assistance.pdf • Center for Benefit’s LIS/Extra Help Eligibility & Benefits chart at: http://www.ncoa.org/assets/files/pdf/center-for-benefits/part-d-lis-eligibility-and-benefits-chart.pdf (Note: Chart applies to 2013) • Center for Benefit’s Fall Guide to Mailings & Key Events at: http://www.ncoa.org/assets/files/pdf/center-for-benefits/AEP-Guide-to-Mailings-and-Key-Events.pdf

26. Thank You! • Thank you for participating in the Benefits Series of the National Center for Benefits Outreach and Enrollment • We invite you to learn more about us by visiting our website: www.CenterforBenefits.org • If you have questions or comments, please contact us at centerforbenefits@ncoa.org