Client As Extra Help And Is Paying More Than He Would If He Didn't Have Lis

[policywunk]

Are the the PDP carriers required to charge the 25% for level 4 Lis even if regular co payment without LIS would be less ? I have seen this issue in the past but not recently until now.At the 25% level he has to pay 145.00 for Entresto instead of the 45.00 copayment of the plan and all his generics are 25% instead of 0 copayment .He is using mail order if that makes a difference.Can someone withdraw/cancel their extra help if it hurts them?

 

[axeman462]

you might want to verify his LIS level. that don't sound right

 

[policywunk]

you might want to verify his LIS level. that don't sound right

I did verify his LIS and he is at 25% level also the math adds up because 25% of the cost of entresto $ 580.93 is what he has been paying all year instead (145.23) instead of the 47.00 tier 3 copayment of plan.I have seen this happen in the past .I have seen it where one pdp carrier was doing this but another wasn't but I thought they had changed that.In this case it is UHC.



Entresto 49-51mg tablet $580.93 $47.00 $145.23

 

[yorkriver1]

Helpful post. I hadn't realized this until running drug cost for someone on 100% LIS, where they pay the small copay, but with some RX plans they would pay $0.
A 25% case:
I helped someone get LIS, and it's the 25% level--the first one I have encountered--done so he could use SEP to get Rx coverage, and put him in an MAPD to get away from the lack of max out of pocket on original Medicare. It also prevents him from the penalty for not having drug coverage for over a year after qualifying for Medicare.
I am now questioning the value of Extra Help due to the Rx cost. Will need to run that and see.
Also insists on keeping the PDP as opposed to his surgeon, even though his treasured surgeon is not in the same network. I am considering suggesting he drop MAPD and just have original Medicare and Rx plan. At below 200% of FPL he is supposed to get hospital bills waived in our state. Had temp Medicaid last year for medical bills also.

 

[policywunk]

Helpful post. I hadn't realized this until running drug cost for someone on 100% LIS, where they pay the small copay, but with some RX plans they would pay $0.
A 25% case:
I helped someone get LIS, and it's the 25% level--the first one I have encountered--done so he could use SEP to get Rx coverage, and put him in an MAPD to get away from the lack of max out of pocket on original Medicare. It also prevents him from the penalty for not having drug coverage for over a year after qualifying for Medicare.
I am now questioning the value of Extra Help due to the Rx cost. Will need to run that and see.
Also insists on keeping the PDP as opposed to his surgeon, even though his treasured surgeon is not in the same network. I am considering suggesting he drop MAPD and just have original Medicare and Rx plan. At below 200% of FPL he is supposed to get hospital bills waived in our state. Had temp Medicaid last year for medical bills also.

Client asked me if can reject extra help for 2021 and actually in his case it would save him about about 100.00 a month for his current rx list.If he can't reject it because it has already been re-approved for 2021 he asked if he could state he has some type of asset over the 15000.00 limit that would make him in eligible.I am certainly not going to put my ass on the line and advise him to do that but I believe he has already figured it out.

Does anybody know if all the PDP carriers now are going to have to charge the LIS copay ment level regardless of what the plan co payments are? If so we need to be careful when advising those with 25% LIS so we don't get nasty phone calls in January.

 

[TwoCents]

Where is everyone getting a 25% number for partial LIS? It's 15%. This is what CMS has to say from the Part D manual Chapter 13 "Premium and Cost-Sharing Subsidies for Low-Income Individuals" -- "Partial subsidy eligible individuals will be subject to a reduction in cost-sharing to 15% coinsurance after any deductible described in section 60.3.1 has been met. If the Part D plan charges cost-sharing that is less than 15% coinsurance, no further reduction is taken." My understanding is that once the deductible is met then lower copays would apply. I don't feel like fact checking that right now.

 

[yorkriver1]

Where is everyone getting a 25% number for partial LIS? It's 15%. This is what CMS has to say from the Part D manual Chapter 13 "Premium and Cost-Sharing Subsidies for Low-Income Individuals" -- "Partial subsidy eligible individuals will be subject to a reduction in cost-sharing to 15% coinsurance after any deductible described in section 60.3.1 has been met. If the Part D plan charges cost-sharing that is less than 15% coinsurance, no further reduction is taken." My understanding is that once the deductible is met then lower copays would apply. I don't feel like fact checking that right now.

From Medicare.gov quote process, do you have extra help, if the answer is yes, this follows:
What percentage do you pay for your monthly prescription drug plan premium?
0%
25%
50%
75%
I'm not sure
So are we referring to the portion of the premium discounted being 25% and mistaking that for the coinsurance on actual drug costs? Maybe.