Explanation of the LIS Worksheet
February 22, 2014
What Is The LIS Worksheet?
The Low Income Subsidy (LIS or Extra Help) worksheet is a simple 2-page set of questions that, if answered correctly, will enable a Virginia Insurance Counseling & Assistance Program (VICAP) counselor to assist a Medicare beneficiary in receivinghelp in paying for his drugs. This same procedure also can help a Medicare beneficiary receive a letter of denial as requested by the New River Valley Medication Assistance Program so that it can provide some free brand name drugs from the pharmaceutical companies.
When you submit this form, you are reporting information to the federal government and giving them permission to verify it in order to award you a benefit. All information should be as accurate as possible. The completedform should be mailed to NRV Agency on Aging, VICAP, 141 E Main St Suite 500, Pulaski, VA 24301.
What Do You Need to Complete the LIS Worksheet?
There must be at least one person in the household who is a Medicare beneficiary and who qualifies for a Medicare Part D drug plan. This benefit does not work with drug plans provided by employers. If both members of the married couple are Medicare beneficiaries qualifying for Part D drug plans, both can apply at the same time. Even if only one member of a married couple is applying for LIS, the financial information for both members must be provided because qualifications depend upon family income.
The personal information needed is name, address, telephone number, birthday, marital status, and Social Security number.
The resources information must be combined if an applicant is married. The resources information needed is total of all bank accounts (checking, savings), all certificates of deposit (CD's), cash, real estate other than home, all savings bonds, mutual funds, stocks, bonds, and IRA's.
The income information must be provided separately for each individual. It consists of Social Security or disability (SSDI) income, Railroad Retirement benefits, Veterans' benefits, other pensions, and other income, such as rent, alimony, and child support.All amounts must be gross, meaning before any deductions are taken from them.
The wage information must be provided if either the beneficiary or spouse has worked in the last 2 years. If neither has worked, this section can be skipped. If either is still working, an estimate of current year's salary must be entered. If either worked last year but not this year, last year's salary must be entered. If either stopped working or plans to stop working, the date last worked must be entered.
Explanation of Data:
Personal Data:
Most of the information requested here is self-explanatory.
Marital Status: Married living together, separated, divorced, single, widowed.
Number in family other than beneficiary & Spouse: This applies only to people who receive half or more of their support from the beneficiary and spouse. (Ex: Grandchildren). This does not apply to self-supporting adult children who live with you.
Resources:
Most of the information requested here is self-explanatory.
Your home and the land it sits on is not counted.
Income:
Most of the information requested here is self-explanatory.
Other pensions and annuities refers to pensions from jobs held.
Other income refers to income otherthan that noted above or wages, such as workers' compensation, alimony, etc.
Wages:
This section applies only if the beneficiary or spouse has worked in the last 2 years.
If either is still working and intends to continue working, wages (or earnings if self-employed) refers to estimated income this year. If either plans to cease working this year, the estimated date that he plans to quit working is needed.
If either quit working this year, wages (or earnings if self-employed) refers to estimated income this year. If either quitworking this year, the date that he quit working is needed.
If either quit working last year, wages (or earnings if self-employed) refers to income last year. If either quit working last year, the date that he quit working is needed.