A Healthy CollaborationSM

Low Income Subsidy Assistance

Background on Low-Income Subsidy Deeming

The low-income subsidy (LIS) is extra help for people with Medicare who have limited income and resources to help pay their Medicare prescription drug plan costs (plan monthly premiums, co-payments and the annual deductible). Certain groups of Medicare beneficiaries are automatically deemed eligible for LIS. These groups include full benefit dual eligible individuals, partial dual eligible individuals (i.e., those who belong to a Medicare Savings Program as a Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary or Qualifying Individual), and people who receive Supplemental Security Income (SSI) benefits but not Medicaid. Other individuals with limited incomes and resources who do not automatically qualify can apply for a low income subsidy and have their eligibility determined by either the Social Security Administration (SSA) or their State Medicaid Agency. Table 1 provides an overview of how people qualify for LIS.

Table 1. Overview of how people qualify for LIS
People with Medicare and Basis Data Source Changes During the Year
Medicaid benefits
  • Full Medicaid benefits
  • Medicare Savings Program
Automatically
qualify
State files
  • Qualify for a full calendar year
  • Generally only favorable change will occur
SSI Benefits SSA
Limited Income and Resources Must Apply SSA (Almost all) or states
  • Some events can impact status through the year
  • Extra help can increase, decrease, or terminate

Background on Best Available Evidence Policy

Best available evidence policy is used when the low-income subsidy information in CMS’ systems is not correct. CMS relies on monthly files from the states and Social Security to establish an individual’s low-income subsidy deemed eligibility and appropriate cost-sharing level. In certain cases, CMS systems do not reflect a beneficiary’s correct LIS deemed status. This may occur, for example, because a state has been unable to successfully report the beneficiary as Medicaid eligible or is not reporting him/her as institutionalized.

Best Available Evidence is a document that shows you qualify. Once Today's Options validates the Best Available Evidence with Medicaid/Medicare, we will update your Low Income Subsidy Assistance status as quickly as possible.

Documents that show you qualify are listed. Please print the checklist, and mark the documents you send (include the checklist as well).

You may fax or mail copies of your Best Available Evidence along with the checklist to us. Fax directly to Member Services team at 1-866-245-5194

Or mail to:
Today's Options
4888 Loop Central Drive
Suite 700
Houston, TX 77081

For more information on Low income subsidy and BAE, you may visit CMS at
www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp.

M0018_PFFSWebv4_1208 CMS (1/2009) Last updated: 1/1/2022

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