Below is a comparison of the Standard Benefit Model Plan parameters as released by The Centers for Medicare and Medicaid Services (CMS) for the plan years 2022 through 2006.
The resource limits have been announced for 2020: $7,860 for a single individual for the full subsidy without the burial expense allowance and $9,360 with it $11,800 for a married couple for the full subsidy without the burial expense allowance and $14,800 with it. The resource limits have been announced for 2020: $7,860 for a single individual for the full subsidy without the burial expense allowance and $9,360 with it $11,800 for a married couple for the full subsidy without the burial expense allowance and $14,800 with it. 2020 This is a summary of drug and health services covered by ConnectiCare Inc., January 1, 2020 – December 31, 2020. This is the most you pay for copays, coinsurance and other costs for medical services for the year. Premiums may be reduced based on Low-Income Subsidy.
| Medicare Part D Benefit Parameters for Defined Standard Benefit 2006 through 2022 Comparison | |||||||||||||||||
| Part D Standard Benefit Design Parameters: | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 |
| Deductible - After the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. | $480 | $445 | $435 | $415 | $405 | $400 | $360 | $320 | $310 | $325 | $320 | $310 | $310 | $295 | $275 | $265 | $250 |
| Initial Coverage Limit - Coverage Gap (Donut Hole) begins at this point. (The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold) | $4,430 | $4,130 | $4,020 | $3,820 | $3,750 | $3,700 | $3,310 | $2,960 | $2,850 | $2,970 | $2,930 | $2,840 | $2,830 | $2,700 | $2,510 | $2,400 | $2,250 |
| Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole. | $7,050 | $6,550 | $6,350 | $5,100 | $5,000 | $4,950 | $4,850 | $4,700 | $4,550 | $4,750 | $4,700 | $4,550 | $4,550 | $4,350 | $4,050 | $3,850 | $3,600 |
| Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point. See note (1) below. | $10,012.50 (1) | $9,313.75 (1) | $9,038.75 (1) | $7,653.75 (1) | $7,508.75 (1) | $7,425.00 (1) | $7,062.50 (1) | $6,680.00 (1) | $6,455.00 (1) | $6,733.75 (1) | $6,657.50 (1) | $6,447.50 (1) | $6,440.00 plus a $250 rebate | $6,153.75 | $5,726.25 | $5,451.25 | $5,100.00 |
| Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2). | $10,690.20 plus a 75% discount on all formulary drugs | $10,048.39 plus a 75% discount on all formulary drugs | $9,719.38 plus a 75% discount on all formulary drugs | $8,139.54 plus a 75% brand discount | $8,417.60 plus a 65% brand discount | $8,071.16 plus a 60% brand discount | $7,515.22 plus a 55% brand discount | $7,061.76 plus a 55% brand discount | $6,690.77 plus a 52.50% brand discount | $6,954.52 plus a 52.50% brand discount | $6,730.39 plus a 50% brand discount | $6,483.72 plus a 50% brand discount | |||||
| Catastrophic Coverage Benefit: | |||||||||||||||||
| Generic/Preferred Multi-Source Drug (3) | $3.95 (3) | $3.70 (3) | $3.60 (3) | $3.40 (3) | $3.35 (3) | $3.30 (3) | $2.95 (3) | $2.65 (3) | $2.55 (3) | $2.65 (3) | $2.60 (3) | $2.50 (3) | $2.50 (3) | $2.40 (3) | $2.25 (3) | $2.15 (3) | $2.00 (3) |
| Other Drugs (3) | $9.85 (3) | $9.20 (3) | $8.95 (3) | $8.50 (3) | $8.35 (3) | $8.25 (3) | $7.40 (3) | $6.60 (3) | $6.35 (3) | $6.60 (3) | $6.50 (3) | $6.30 (3) | $6.30 (3) | $6.00 (3) | $5.60 (3) | $5.35 (3) | $5.00 (3) |
| Part D Full Benefit Dual Eligible (FBDE) Parameters: | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 |
| • Deductible | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Copayments for Institutionalized Beneficiaries | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Maximum Copayments for Non-Institutionalized Beneficiaries | |||||||||||||||||
| Up to or at 100% FPL: | |||||||||||||||||
| • Up to Out-of-Pocket Threshold | |||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $1.35 | $1.30 | $1.30 | $1.25 | $1.25 | $1.20 | $1.20 | $1.20 | $1.20 | $1.15 | $1.10 | $1.10 | $1.10 | $1.10 | $1.05 | $1.00 | $1.00 |
| - Other Drugs | $4.00 | $4.00 | $3.90 | $3.80 | $3.70 | $3.70 | $3.60 | $3.60 | $3.60 | $3.50 | $3.30 | $3.30 | $3.30 | $3.20 | $3.10 | $3.10 | $3.00 |
| • Above Out-of-Pocket Threshold | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
| Over 100% FPL: | |||||||||||||||||
| • Up to Out-of-Pocket Threshold | |||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| • Above Out-of-Pocket Threshold | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Part D Full Subsidy - Non Full Benefit Dual Eligible Full Subsidy Parameters: | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 |
| Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources ≤ $9,470 (individuals in 2021) or ≤ $14,960 (couples, 2021) (4) | |||||||||||||||||
| • Deductible | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Maximum Copayments up to Out-of-Pocket Threshold | |||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| • Maximum Copay above Out-of-Pocket Threshold | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Partial Subsidy Parameters: | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 |
| Applied and income below 150% FPL and resources between $14,790 (individual, 2021) or $29,520 (couples, 2021) (category code 4) (4) | |||||||||||||||||
| • Deductible | $99.00 | $92.00 | $89.00 | $85.00 | $83.00 | $82.00 | $74.00 | $66.00 | $63.00 | $66.00 | $65.00 | $63.00 | $63.00 | $60.00 | $56.00 | $53.00 | $50.00 |
| • Coinsurance up to Out-of-Pocket Threshold | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% |
| • Maximum Copayments above Out-of-Pocket Threshold | |||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| (1) Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries - Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS) | |||||||||||||||||
| (2) Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries - Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2022, the weighted gap coinsurance factor is 89.1745%. This is based on the 2020 PDEs (91.76% Brands & 8.24% Generics) | |||||||||||||||||
| (3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2022, beneficiaries will be charged $3.95 for those generic or preferred multisource drugs with a retail price under $79 and 5% for those with a retail price greater than $79. For brand-name drugs, beneficiaries would pay $9.85 for those drugs with a retail price under $197 and 5% for those with a retail price over $197. | |||||||||||||||||
| (4) This amount includes the $1,500 per person burial allowance. The resource limit may be updated during contract year 2022. | |||||||||||||||||
Sign-up for our 2022 Reminder Service
DHS home | SPD Staff tools | MMA manual | B. The Low-Income Subsidy (LIS) and copayments |
MMA Manual
Updated 1/1/21
B. The Low-Income Subsidy (LIS) and copayments
The amount a person pays depends on their income, whether they use generic or brand name drugs, and whether he or she is institutionalized or not. Clients may fall into 3 categories for the Low-Income Subsidy (LIS).Full dual-eligible clients with incomes above 100% of FPL fall into LIS Category 1, paying $3.70 for generic drugs and $9.20 for brand name drugs. Those individuals with incomes at or below 100% of the federal poverty level fall into LIS Category 2 ($1.30/generic & $4.00/brand name). Institutionalized and/or Home and Community based, full-dual clients fall into LIS Category 3, which eliminates copayments.
Medicare Low Income Subsidy Chart
Medicare Savings Program clients, who do not also have full Medicaid, will always be in LIS Category 1. See the 2021 LIS Reference Sheet.
1. Others with Limited Income
Other Medicare beneficiaries with limited income, including SNAP-only clients, may apply for the Low-Income Subsidy through the Social Security Administration (SSA). They complete the application form by providing their income, resources, and family size. Applications can be completed at www.ssa.gov. If the Social Security Administration determines that an individual is qualified for the extra help, he or she will fall within one of the categories outlined in the 2021 LIS Reference Sheet. The Social Security Administration does not have an Estate Recovery Program for any LIS assistance. If an individual falls within the following guidelines, they should be referred to SSA:
- Annual Income limited to $18,735 for an individual or $25,365 for a married couple living together in 2020 (updated each March).
- Resources limited to $14,610 for an individual or $29,160 for a married couple living together in 2019. Resources include such things as bank accounts, stocks and bonds. We do not count their house and car as resources.
People with Medicare and Medicaid, Medicare Savings Program (MSP) enrollment, or those receiving Supplemental Security Income are automatically eligible for the extra help. People in these programs are “Deemed Eligible”. They do not need to apply for the LIS and do not need to meet the resource limit (as of 2016).
If a person with Medicare loses his or her state medical assistance or MSP eligibility prior to July, he or she will no longer be automatically eligible for the extra help for the next calendar year. The individual must apply for the extra help with the Social Security Administration (SSA) to continue receiving low copayments for their Medicare Part D covered drugs for the following year.
2. LIS Effective Dates
The Low-Income Subsidy is effective the first day of the month of dual eligibility status.
Example: A client applies on August 10th, but does not get all of his paper work in until September 5th would have his Medicaid effective on August 10th would have LIS effective retroactively to August 1st.
The exception to this rule is for any client “institutionalized” for MMA purposes. All 34 pokemon game downloads. The institutionalized LIS Level 3 is not effective until the 1st of the month in which it is reasonably expected that the dual-eligible client will remain in the facility for a full calendar month, in which Medicaid is paying.
Example: A private pay individual in a facility meets the OSIPM criteria on May 7th and becomes a dual-eligible on that date. The LTC payments begin on that date, as well. It is believed that the client will not be leaving the facility for several months. The LIS level 3 for this client would begin on June 1st.
It is critical that the case is properly coded with the “ISI” case descriptors when it is anticipated that the client will be in a facility for a full month. The “ISI” case descriptor should be removed as soon as the client leaves the facility. Alias full movie.
Lis Drug Copays 2020
If you have a disability and need a document on this Web site to be provided to you in another format, please contact the Office of Document Management (ODM) at 503-378-3486 or by e-mail at dhs.forms@state.or.us.
If you have questions about DHS or problems getting DHS services, send e-mail to dhs.info@state.or.us. If you have comments about this site, send e-mail to spd.web@state.or.us.
Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
Toll-free: (800) 282-8096 (V/TTY)