CMS Has New Tip Sheets on Best Available Evidence and Making Sure LIS Beneficiaries Pay Correct Copays

CMS Has New Tip Sheets on Best Available Evidence and Making Sure LIS Beneficiaries Pay Correct Copays

The Centers for Medicare and Medicaid Services (CMS) recently posted 2 new tip sheets:

  1. on Best Available Evidence (BAE) – “Correcting Beneficiary Low-Income Status Based on Best Available Evidence” and
  2. on making sure beneficiaries who may qualify for the low-income subsidy (LIS) are paying the correct co-payment amounts – “Are You Paying the Right Amount for Your Prescriptions?

Both tip sheets provide an important review for beneficiaries and advocates on easy, clear steps to take if one qualifies for the low-income subsidy (LIS) and is being charged too much for their Part D prescription drug co-pays.

The first tip sheet on BAE explains how Medicare uses data both from the state Medicaid offices and Social Security to determine who is eligible for the LIS program. Sometimes, however, Medicare’s system shows incorrect payment levels or may not show that a person is eligible for LIS when they are. In such cases, beneficiaries can use one of the outlined best available evidence methods to demonstrate to their Part D plans they are indeed eligible to receive the low-income subsidy. Once a Part D plan receives any form of BAE documentation, they must charge the beneficiary no more than $2.40 for a generic drug and $6.00 for a brand name drug (in 2009). If a beneficiary is in an institution, they cannot charge him/her any co-payment amount for either generic or brand name drugs.

If a beneficiary cannot find one of the 9 pieces of BAE documentation outlined on the tip sheet, but still think they are eligible for the LIS, they can call their Part D plan for help. Their plan must refer their information to Medicare to verify their status, and they must do this within 1 business day.

For more information, view the 2 tip sheets. Also, see our previous newsletter article “CMS Issues Updated Best Available Evidence Policy Memo to Part D Plans.”

In addition, see our fact sheet on “Extra Help for Part D Costs.”

Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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