CASE FLASH: DOCUMENTING “EXTRA HELP” (LIS)

Ms. S has a Medicare Savings Program (MSP), and was thus automatically enrolled in full Extra Help (also known as the Low Income Subsidy or LIS), a federal program that helps pay for most of the costs of the Medicare drug benefit. With full Extra Help, Ms. S should never pay more than $2.15 for her generic prescriptions and $5.35 for her brand-name prescriptions. When she went to the pharmacy to fill her prescriptions, though, Ms. S was charged much more. When she called her Medicare private health plan that offers her Medicare drug coverage, to ask why this was happening, she was told by the customer service representative that there was no record of her having Extra Help in their system. Ms. S called her local State Health Insurance Assistance Program (SHIP) for help.

A SHIP counselor told Ms. S that Medicare private drug plans are required to accept proof of Extra Help eligibility from a plan member at the pharmacy. The counselor advised Ms. S to take proof of having an MSP with her to the pharmacy so that she would be charged the only the full Extra Help copays for her drugs. She was also advised to send proof of having an MSP directly to the plan, just to be sure that the situation is fixed for the next time.

Proof of Extra Help include:

• an award letter from the Social Security Administration or Medicare saying that the member has been enrolled in Extra Help;
• a Medicaid card (in which case the maximum co-pay would be even less - $3) ;
• a letter from the state notifying the member that she/he has a Medicare Savings Program;
• a letter from Social Security saying the member has Supplemental Security Insurance (SSI)

Since she had already gone to the pharmacy, MS. S faxed her Medicare private drug plan MSP Notice of Action, which states the date on which she began receiving her Medicare Savings Program benefits. The plan did add her Extra Help status to their system. Now, Ms. S is charged the proper copays for her on-formulary drugs when she goes to a pharmacy in her plan's network. In addition, by submitting her plan's reimbursement form and the receipts for the drugs she had already overpaid for, she can get her money back.

- Adapted from:Welcome to Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 10, No. 2: January 23, 2007

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