2146 Low Income Subsidy (Extra Help for Medicare Part D) | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Low Income Subsidy (Extra Help for Medicare Part D)

Effective Date:

February 2020

Chapter:

2100

Policy Number:

2146

Previous Policy Number(s):

MT 55

Updated or Reviewed in MT:

MT-59

Requirements

Certain Medicare recipients may be eligible to receive a Low-Income Subsidy (LIS) to help pay for the expenses incurred under Medicare Part D.

Basic Considerations

Anyone may apply for the LIS. However, to be eligible to receive the LIS or Extra Help, an A/R must meet the following conditions:

Be eligible for or enrolled in Medicare Parts A and B AND
Be a recipient for full Medicaid benefits,
OR Q Track,
OR have limited income and resources (Refer to Appendix A1 for current limits.)

If the Medicare recipient is determined eligible for the LIS, s/he will not be reimbursed for any out of pocket Medicare Part D expenses incurred. Once that information is updated in Social Security’s and/or Centers for Medicaid and Medicare Services' system, then the premiums and deductibles should be covered.

Procedures

DFCS staff may be requested to assist in helping Medicare recipients apply for the LIS. The LIS application (LISA) is completed on a Form SSA -1020B – OCR-SM. Applications may be accepted as early as May 2005. If the Medicare recipient insists on having the State determine the eligibility for the LIS, contact your Medicaid Program Specialist.

Also see Sections 2751 and 2931 for more information.

Follow the steps below in completing the LISA:

Step 1	The LISA MUST be completed on an original Form SSA-1020B. Photocopies should only be made for filing purposes and/or to determine eligibility for Medicaid COAs. Recipients may come with their own LISA application on which some information may be preprinted. If not, provide the recipient with the LISA and complete needed information.
Step 2	Refer recipients to GeorgiaCares (1-800-669-8387) for the Prescription Plan explanations and help in enrolling in the Medicare Part D. Refer to Section 2931, Medicare Part D.
Step 3	Complete one application for legally married couples living together. For others complete an individual application.
Step 4	Complete application using ONLY black ink or # 2 pencil. Any block which must be “checked” should be done using an X.
Step 5	Even though there is not a “field” provided, write the date the application was taken in the upper right-hand corner of the LISA in the MMDDYYYY format. This date must be handwritten as a date stamp will void the form.
Step 6	In the State code blocks, enter GA. Do not mark “WBDOC Exception” Official Use in Wilkes-Barre Only.
Step 7	Print the recipient’s name and SSN in the blocks provided in number 1 of the LISA, beginning with the Last Name. Make sure it matches the Medicare card.
Step 8	If recipient is legally married, print the spouse’s name and SSN in the blocks provided in number 2, beginning with the Last Name. Make sure it matches the Medicare card. Be sure to check whether the application is for one spouse or both.
Step 9	When completing numbers 3 - 7, remember resource exclusions for FBR COAs, such as $1500 burial exclusion per person, $3000 per couple ($5000/$10,000 non FBR), homeplace, vehicle, etc. Accept the recipient’s statement as to the value of assets. It is not necessary to verify unless this application is also used for a Medicaid COA which requires verification.
Step 10	Question number 8 address household size. Make sure, for purposes of the LISA, the recipient understands that s/he will have a higher income limit based as the household size increases. Include any relative (related by blood, marriage or adoption) in the household size for which the recipient provides at least one-half of the financial support. Refer to Appendix A1 for Federal Poverty Level Tables.
Step 11	Number 9 refers to unearned income. Do not enter RSDI or SSI income. However, if the application will be used for a Medicaid application, ask and accept the recipient’s statement regarding RSDI/SSI income. Annotate on the copy only. Enter the gross amounts of any other unearned income based on what the recipient tells you. It is not necessary to verify unless this application is also used for a Medicaid COA, which requires verification.
Step 12	In number 11, enter the amount the recipient reports as being provided.
Step 13	Numbers 12 – 16 refer to earned income. Accept the recipient’s statement as to the amount of earnings. It is not necessary to verify unless this application is also used for a Medicaid COA which requires verification.
Step 14	Page 6 is the signature page. Both the recipient and spouse should sign in Section A, if available. If one or both are not available, a representative may sign for them. The MES should sign in Section B. Enter an X in “Other” and “Georgia DFCS” in the space provided.
Step 15	Make 2 copies of the form. Give one copy to the recipient or the person acting on their behalf. Use the other to screen for Medicaid and FS eligibility the same day the LISA is completed. If the A/R appears to be potentially eligible for FS provide him/her with a Form 297 to apply for the FS using the current date as the application date. If the recipient appears eligible for a Medicaid COA, follow regular application processing standards. Another Medicaid application form is not required although additional information and verifications may be required. If the A/R is ineligible for ANY Medicaid COA, then register and deny on Georgia Gateway
Step 16	If the A/R is Medicaid eligible, do not send the 1020 to SSA. If the A/R is NOT Medicaid eligible, mail the ORIGINAL LISA the same day as completed in the postage paid envelope to: Social Security Administration Wilkes Barre Data Operations Center P.O. Box 1020 Wilkes Barre, Pennsylvania 18767-1020 Additional LISAs may be obtained from your local SSA.