ADDENDUM 6
MEDICARE PART D LOW INCOME SUBSIDY GUIDE
Effective January 1, 2015
Category |
Full Subsidy Eligible |
Reduced Subsidy Eligible |
Full Benefit Dual Eligible |
Standard Medicare Beneficiaries (Not LIS Eligible) |
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Description |
Premium, deductible and cost sharing subsidy for low-income Medicare Part D recipients. |
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Application Form |
SSA 1020 - Application |
SSA 1020 - Application |
None - State transmits eligibility file to SSA |
N/A |
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Income |
<135% FPL |
<150% FPL |
Dual Eligible (100% FPL) |
Dual Eligible (>100% FPL) |
Dual Eligible (Institutionalized) |
Deemed Eligible Medicare Premium
SLMB = <120% FPL>
SLMB Plus = <135% FPL> |
>150% FPL |
Resource Limit |
$7,160 Single
$10,750 Couple |
$13,440 Single
$26,860 Couple |
None |
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Prescription Drug Plan |
Facilitated Auto-Enroll |
Recipient Enrolls |
Auto-Enrolled |
Auto-Enrolled |
Auto-Enrolled |
Auto-Enrolled |
Voluntary Enrolls |
Recipient
Premiums
Deductibles
And
Co-Pays |
$0 premium
No Deductible
$2.55 or $6.35 co-pay $0 co-pay after $4,550 out-of-pocket expenses |
Sliding scale premium
$63 Deductible
15% co-insurance $2.55 - $6.35 co-pay after $4,550 out-of-pocket expenses |
$0 premium
No Deductible
$1.20 or $3.60 co-pay $0 co-pay after $4,550 out-of-pocket expenses |
$0
premium
No Deductible
$2.55 or $6.35 co-pay;
$0 co-pay after $4,550 out-of-pocket expenses |
$0 premium
No Deductible
$0 co-pay |
$0 premium
No Deductible
$2.55 or $6.35 co-pay $0 co-pay after $4,550 out-of-pocket expenses |
100%
premium
$325
Deductible 25%
co-insurance up to $2,850 total spending ($661.25) 100%
co-pay between $2,850 and $6,455 total spending** |
Coverage Gap |
None |
None |
None |
None |
None |
None |
** Yes |
Corresponding EIS Medicaid Subtype |
SI = SSI
ST = APA eligible
QM = QMB
NS = Ineligible for SSI /APA due to requirements that do not apply to Medicaid |
AS = Waiver in Asst. Living
BB = Lost SSI /APA due to1977 SSA COLA
BC = Breast & Cervical Cancer
DW = Working Disabled Buy-In
GF = Eligible for MED in 1973
IN = HCB Waiver
PM = 1619b, Disabled Adult Children, Disabled Widowers
QD = Qualified Disabled & Working Individuals
RC = Refuse Cash
SS = Eligible for AF/SSI /APA in 1972
ST = APA Eligible |
NH = Nursing Home |
SL = SLMB |
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