Low-Income Subsidy

The Low-Income Subsidy (LIS) Program gives you extra help to pay for your Medicare Prescription drug plan costs.

With LIS, your monthly premium will be lower than if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium.

CHPW Medicare Advantage premiums listed are for both medical services and prescription drug benefits.

2021 Low-Income Subsidy Premiums

These tables show you what your monthly plan premium will be depending on your level of extra help.

Your level of extra help	MA PLAN 3 (HMO) 008	MA PLAN 4 (HMO) 009	MA PLAN 2 (HMO) 010	MA DUAL PLAN (HMO SNP) 014
100%	$0.00	$0.00	$0.00	$0.00
75%	$8.70	$5.50	$6.60	$9.00
50%	$17.50	$11.00	$13.20	$18.00
25%	$26.20	$16.50	$19.90	$27.00

The premiums listed above do not include any Medicare Part B premium you may have to pay. CHPW Medicare Advantage premiums listed are for both medical services and prescription drug benefits.

If you are not getting extra help, you can see if you qualify by calling:

• 1-800-MEDICARE or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week).
• Your State Medicaid Office at 1-800-737-0617.
• Social Security at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7:00 a.m. – 7:00 p.m., Monday through Friday.

For more information on Medicare Programs:

1-800-MEDICARE or TTY call 1-877-486-2047, 24 hours a day, 7 days a week, or visit their website.

For more information on Washington State Medicaid Programs:

1-800-562-3022 or TTY call 1-800-848-5429, 7:00 a.m. to 6:00 p.m., Monday – Friday, or visit their website.

For more information on the Low-Income Subsidy Program:

1-800-772-1213 or TTY call 1-800-325-0778, 7:00 a.m. to 7:00 p.m., Monday – Friday, or visit their website.

Best Available Evidence

If you believe you qualify for Low-Income Subsidy (LIS) and are paying the incorrect cost-sharing amount, we can help. Community Health Plan of Washington has a process that allows you to request assistance in obtaining evidence of your proper co-payment level. If you need help obtaining evidence, we can guide you through this process, either over the phone or in your local clinic. We can review your eligibility and help you fill out the necessary forms. Contact customer service at 1-800-942-0247 (TTY Relay: 711), 8 a.m. to 8 p.m., seven days a week.

We follow CMS’ Best Available Evidence (BAE) to determine a member’s LIS.  Members may send BAE documentation to establish eligibility to the Customer Service address listed below or call Customer Service to request assistance.

Acceptable forms of evidence are:

• Your State Medicaid ID Card
• Other evidence from the state showing that you are Medicaid eligible
• SSA letter that shows your SSI effective date
• SSA Award letter that says you are automatically eligible for extra help

As soon as one of the forms of BAE is presented, we will update our system so you can pay the correct copayment when you get your next prescription at the pharmacy.

Documentation can be mailed or faxed to:

Community Health Plan of Washington
Attn: Medicare Advantage
1111 Third Avenue, Suite 400
Seattle, WA 98101
Fax: 1-206-652-7050
You can read our BAE policy here.

CHPW Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in CHPW Medicare Advantage depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact us.