In accordance with the statutory requirement to provide a cost-sharing subsidy to Part D eligible individuals who are full-benefit dual eligible individuals or recipients of supplemental security income (SSI), Troy Medicare must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility, even if our systems and CMS’ systems do not yet reflect that eligibility.
Troy Medicare also must update our systems to reflect the LIS status indicated by the best available evidence and, if necessary, must submit a request to CMS so that, for the deemed population, the agency’s systems can be updated as well. These requirements apply to all beneficiaries who are “deemed” subsidy eligible (including full benefit Medicare/ Medicaid eligibles, partial dual eligibles, and people receiving SSI) as well as those who must apply and are awarded LIS by the Social Security Administration (SSA).
Troy Medicare is required to accept any of the following forms of evidence to establish the subsidy status of a full benefit dual eligible beneficiary when provided by the beneficiary or the beneficiary’s pharmacist, advocate, representative, family member or other individual acting on behalf of the beneficiary:
- A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date during a month after June of the previous calendar year;
- A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year;
- A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year;
- Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year; or,
For individuals who are not deemed eligible, but who apply and are found LIS eligible, a copy of the SSA award letter.
Troy Medicare must also accept any one of the following forms of evidence from beneficiaries or pharmacists to establish that a beneficiary is institutionalized and qualifies for zero cost-sharing:
- A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year;
- A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year; or
- A screen print from the State’s Medicaid systems showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.
As soon as one of the forms of BAE listed above is presented, Troy Medicare must provide the beneficiary access to covered Part D drugs at a reduced cost-sharing level which is no greater than the higher of the LIS cost-sharing levels for full subsidy eligibles (in 2025, this level is $4.90 per generic or preferred brand name drug; $12.15 per brand name drug), or at zero cost-sharing if the BAE also verifies the beneficiary’s institutional status.
Once Best Available Evidence is supplied, Troy Medicare will update our systems to reflect the correct LIS status, override standard cost-sharing, and maintain an exceptions process for the beneficiary to obviate the need to require the re-submission of documentation each month pending the correction of the beneficiary’s LIS status in CMS systems. We will update our systems within 48-72 hours of our receipt of BAE documentation. This is in addition to the requirement that we provide access to covered Part D drugs as soon as BAE is presented.
In addition to the requirements clarified above, there is also a process for assisting individuals who claim to be subsidy eligible based on being full or partial dual eligibles but who cannot provide the documentation described above. As part of this process, Troy Medicare is required to take the following actions:
- Complete CMS BAE Assistance worksheet with plan and beneficiary information.
- Ask the beneficiary (or the beneficiary’s advocate, pharmacist, authorized representative or other individual acting on the beneficiary’s behalf) what date the beneficiary will run out of medication.
Troy Medicare will then send the worksheet via an encrypted e-mail to the CMS RO Part D mailbox based on where the individual resides for review. The CMS RO will attempt to confirm with the State Medicaid agency whether the beneficiary is eligible for LIS, and will return the worksheet to Troy Medicare with confirmation of LIS status.
Troy Medicare will then notify the beneficiary of the results of CMS’ inquiry. If we receive confirmation from the CMS RO that a beneficiary is subsidy eligible, Troy Medicare must provide the beneficiary access to covered Part D drugs at a reduced cost-sharing level no greater than the higher of the LIS cost-sharing levels for full subsidy eligibles (in 2023, this level is $4.15 per generic or preferred brand drug; $10.35 per brand name drug), or at zero cost-sharing if the RO also verifies the beneficiary’s institutional status.
For more information regarding “Best Available Evidence” Click Here to visit the CMS website address.
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