Best Available Evidence Policy
Federal regulations at 42 CFR § 423.800 specify requirements for Medicare Advantage Plans with Part D coverage (like Simpra Advantage) to follow when administering the Low-Income Subsidy Program, or LIS. The LIS regulations include reducing the cost sharing for those members who are eligible for the subsidy. There may be times when the CMS systems do not reflect the beneficiary’s correct low-income subsidy status. This occurs because the beneficiary’s most up-to-date and accurate subsidy information has not been communicated to the Plan.
To address these situations, CMS requires the Plan to establish the appropriate cost-sharing for the low-income beneficiary when presented with evidence that the information on file with the Plan for the beneficiary is not accurate. This is called the Best Available Evidence (BAE) Policy.
In line with the BAE policy, Simpra Advantage must accept any one of the following forms of evidence from a beneficiary (or pharmacist) to update the member’s low-income status:
- a copy of the member’s Medicaid card that includes the member’s name and an eligibility date during the discrepant period;
- a report of contact including the date a verification call was made to the State Medicaid Agency and the name, title and telephone number of the state staff person who verified the Medicaid status during the discrepant period;
- a copy of a state document that confirms active Medicaid status during the discrepant period;
- a printout from the State electronic enrollment file showing Medicaid status during the discrepant period;
- a screen print from the State’s Medicaid systems showing Medicaid status during the discrepant period; or
- other documentation provided by the State showing Medicaid status during the discrepant period.
Simpra Advantage must also accept any one of the following forms of evidence from a beneficiary (or pharmacist) to establish that the 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 the discrepant period;
- a copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual; 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 the discrepant period.
If you have any questions, please contact Simpra Advantage Member Services at 1-844-637-4770 (TTY/TDD 1-833-312-0044). Hours of Operation are 8am – 8pm LOCAL TIME, 7 days a week from October 1st – March 31st, 5 days a week from April 1st – September 30th. Member Services is closed on the following Holidays: Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas.