Are You Eligible for Medicaid or LIS?

August 5th, 2015

How to Determine Medicaid and Medicare LIS Eligibility

Medicaid and Low-Income Subsidy are two options for low-income individuals who may need a little extra help making ends meat when paying for healthcare costs. Medicaid provides free or low-cost health coverage to any low income person or family who meet eligibility criteria, while the Low-Income Subsidy (LIS) is a program to help Medicare beneficiaries pay for Medicare Part D prescription drug costs.

Many individuals struggle with understanding Medicaid and Medicare LIS qualifications and knowing if they are eligible or not. Common questions include where to find the qualifications, how eligibility is determined, how to sign up and how to select or change a healthcare plan. Many individuals struggle with these questions because the process seems difficult. However, it’s simple to use Healthcare.gov to determine if an individual is eligible for Medicaid.

Medicare Low-Income Subsidy Eligibility

Low Income Subsidy definition

Low-Income Subsidy, or LIS, is a type of “extra help” for Medicare beneficiaries who need prescription drug coverage due to fixed income and limited resources. This subsidy is paid for by the Federal government to provide assistance with most costs including the premium, deductible, and co-payments associated with the Medicare Part D plan. Thirteen million Medicare beneficiaries are currently eligible for LIS. To determine eligibility, you will need:

  • A Social Security card;
  • bank account statements, including checking, savings, and certificates of deposit;
  • Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment statements;
  • tax returns;
  • payroll slips; and
  • your most recent Social Security benefits award letters or statements for Railroad Retirement benefits, Veterans Benefits, pensions and annuities.

You may qualify if:

  • Your assets are less than $13,440 (single individual) or $26,860 (married couple living together)
  • You have an annual income less than $17,235 (single) or $23,265 (married).
  • Your annual income is higher than the eligibility limit, but you support other family members in the same household.

Financial advisors, insurance agents, or individuals can determine eligibility by conducting a “personalized search.” Remember to obtain the person’s zip code, Medicare number, last name, Part A effective date, and their birth date. Enter this information in the “personalized search” section and hit enter. In the upper right-hand corner of the page, you will see a section called “My Current Profile.” Here you will be able to see the person’s zip code, current healthcare coverage, current subsidy and future subsidy. If you or your client still needs to apply for extra help, you can apply here on the Social Security Administration website. It requires the input of personally identifying information including information about their Medicare number and effective date. Medicare agents can utilize these tools to simplify the health insurance application and comparison process, providing more detailed information in a simple format.

Additional Benefits

From there, the next step is to consider BenefitsCheckup.org. It helps to identify additional programs that may provide help to individuals beyond what is provided by the subsidy. These programs may help with taxes, health care, utilities and more. Individuals can apply directly online for this benefit tool and for the available benefits.

How to Determine Medicaid Eligibility

Factors such as household size, income, age and disability status all contribute to determining Medicaid Eligibility. In all states, Medicaid provides free or low-cost healthcare for some low-income people, families and children, pregnant women, the elderly and people with disabilities. In some states, the program covers all adults under a certain income level. Medicaid programs follow federal guidelines, but can vary from state to state.

Because eligibility varies by state, the best way to find out if you are eligible is to use this online screening tool from HeathCare.gov. Start by entering your ZIP code, then select the middle option to find out if you’re eligible for Medicaid.

You will need:

  • Estimated monthly household income for 2015
  • Number of persons in household
  • Age of persons in household
  • Disability status

After completing the screening process, you will be given an opportunity either to start an online application for Medicaid or to see if you qualify for a special enrollment period in the Health Insurance Marketplace.

How Often Can a Beneficiary Change Plans?

Many Americans, at some point, need or want to change their current plan. To change outside of the Annual Election Period (AEP) which runs October 15 – December 7th, the beneficiary must qualify for a Special Election Period (SEP). Some examples of Special circumstances are moving outside the service area, eligibility changes, errors, and other reasons, may allow for plan changes outside of the AEP.

It’s also important to consider Missouri RX or other State pharmaceutical assistance programs. It offers a once in a lifetime SEP change if the beneficiary receives the subsidy. What does this mean? In short, it means that the beneficiary can utilize the SEP at any time only once. The exception applies if the beneficiary obtains Medicaid, which would then default to allow the beneficiary to change at any time with a first of the following month effective day.

Ultimately, the goal is to provide individuals with a plan that meets their needs while maximizing the benefit they can obtain. The process is complex; many Americans struggle with these factors. However, this simple tool can help Medicare agents and health insurance providers to navigate the beneficiary’s options in a more streamlined method.

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