25.1 Medicare - Part A & Part B 25.2 Medicare Part A · 2020. 6. 25. · Medi-Cal Page 25-1 Update #20-02 Medi-Cal 25. Medicare Coverage 25. Medicare Coverage 25.1 Medicare - Part

Medi-CalMedi-Cal 25. Medicare Coverage

25. Medicare Coverage

25.1 Medicare - Part A & Part B

Medicare is a federal health insurance program administered by the Social Security Administration. It provides health insurance benefits to eligible individuals age 65 or over, and to blind and disabled individuals who have been entitled to Retirement, Survivors and Disability Insurance (RSDI) or Railroad Retirement disability benefits for at least 24 consecutive months. A person in need of renal dialysis or a kidney transplant may also qualify for Medicare. Medicare coverage is composed of two parts, Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).

25.2 Medicare Part A

Medicare Part A covers:

• Inpatient hospital care• Inpatient care in a skilled nursing facility for a limited number of days • Hospice Services

Note:

Part A, hospital insurance does not cover physician's services, even when they are received in a hospital.

Individuals eligible for Medicare Part A include:

• An individual age 65 or older who is eligible for RSDI or a Railroad Retirement annuity.

• An individual age 65 or older and ineligible for RSDI or Railroad Retirement benefits who is:

• A U.S. Resident, and

• A U.S. Citizen; or, a Non-citizen lawfully admitted for permanent residence with 5 years of continuous residence.

• Deemed insured, as determined by the Social Security Administration (SSA).

• An individual under age 65 eligible for disability based RSDI or Railroad Retirement benefits, and who has received such benefits for at least 24 consecutive months.

Update #20-02Page 25-1

page 25-2Medi-Cal 25. Medicare Coverage

• An individual, any age, with end-stage renal disease requiring either a kidney transplant or dialysis. The individual must be one of the following:

• Currently receiving RSDI, or• Railroad Retirement benefits, or• Fully or currently insured, or• The spouse or dependent child of an insured person.

25.2.1 Premiums

Medicare Part A is available to eligible individuals at no cost. An individual who does not qualify for free Part A can purchase Part A coverage through payment of a monthly premium if he/she meets all of the following conditions:

• Age 65 and older, and

• A U.S. Resident, and

• A U.S. Citizen; or a noncitizen lawfully admitted for permanent residence with 5 years of continuous residence, and

• Enrolled in Part B. Individuals who purchase Part A must purchase Part B.

Note:Note:A person does not have to be retired to get Medicare.

• Medi-Cal (MC) pays the Part A premium for those individuals eligible for the Qualified Medicare Beneficiaries (QMB) Program or the Qualified Disabled Working Individual (QDWI) Program, if they do not already qualify for free Part A.

25.3 Medicare Part B

Medicare Part B includes, but is not limited to:

• Physician services• Outpatient hospital services• Diagnostic tests• Physical therapy• Limited chiropractic services• Durable medical equipment• Home health services.

Individuals eligible for Medicare Part B include:



• Any individual eligible for Medicare Part A, or

• An individual 65 years and older who is:

• A U.S. Resident, and• A U.S. Citizen; or, a Non-citizen lawfully admitted for permanent residence with 5 years

continuous residence.

Any individual who qualifies for free Part A is automatically eligible to enroll for Part B. For these individuals, there are no citizenship status, immigration or U.S. residency requirements.

25.3.1 Premiums

There is a premium cost for all individuals eligible for Medicare Part B. The premium cost is deducted from the gross benefit amount of those enrolled individuals receiving RSDI or Railroad Retirement payments. Other eligible persons can purchase Part B coverage through payment of a monthly premium.

MC, through the State Buy-In agreement, pays the Part B premiums of all Medicare recipients.The Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) programs are also available to pay for all or some of the Part B premium. [Refer to “Medicare Buy-In,” page 25-11] for complete Buy-In information.]

25.4 How Medicare And Medi-Cal Work Together

25.4.1 Crossover Claims

Individuals who have both Medicare and Medi-Cal are described as having crossover benefits. In order to be paid by both Medicare and Medi-Cal, the provider must agree to accept Medicare's allowable charge as payment in full. After the annual Medicare deductible has been met, Medicare will pay the remaining charges for all Medicare Part A covered services and 80% of the costs of Part B covered services.

Medi-Cal may or may not pay the remaining charges, or a portion of the remaining charges, depending on the Schedule of Maximum Allowances (SMA) fee schedule.

Medicare is the first to pay for any service that is covered by both programs.

If the provider accepts Medi-Cal for a service, he or she may not bill the patient for more than the amount paid by Medicare plus Medi-Cal.

A Medi-Cal patient, who sees a physician or provider who chooses not to accept Medi-Cal, should be advised by that provider, before services are rendered, that:



• He/she is not being accepted as a Medi-Cal patient, or that the provider may not wish to bill Medi-Cal for a particular service.

• The patient will have to pay the additional amount not covered by Medicare.

25.4.2 Medicare Deductibles

Both Medicare Part A and Part B have deductibles which are paid by the patient or Medi-Cal.

• For the Medi-Cal beneficiaries with no share of cost, or a Qualified Medicare Beneficiary (QMB), these deductibles are paid by Medi-Cal.

• A Medi-Cal beneficiary who is responsible for paying the Medicare deductible can have this expense included in meeting the Medi-Cal share of cost, just as other medical expenses do.

25.4.3 Other Services

Medi-Cal pays the cost of some services which are not covered by Medicare (e.g., certain outpatient prescriptions, custodial level nursing care, glasses, some dental services, hearing aids, etc.).

25.5 The Medicare Card

The Medicare card, (the red, white and blue health insurance card) includes the following information:

• Name of the beneficiary.• Medicare Beneficiary Identifier (MBI), as known as Health insurance claim number (HIC).• Date of the beneficiary's entitlement to Medicare Part A and/or Part B.

25.5.1 Medicare Number

The Medicare Number is also referred to as a MBI number for health insurance claim number, Social Security claim number, or Railroad Retirement claim number).

The Medicare number must be 11 alphanumeric characters excluding letters S, L, O, I, B and Z.

The following codes are frequently seen in MBI/HIC numbers:

M = Medicare Only (No SSA benefits)

A = Primary claimant



25.5.2 Issuance

The Social Security Administration or the Railroad Retirement Board is responsible for issuing the Medicare card to eligible persons.

• A new Medicare card is issued whenever a beneficiary's name, Medicare number, or dates of entitlement change.

• Beneficiaries who need to have their Medicare cards corrected or replaced should contact Social Security.

25.6 Individuals Required to Apply for Medicare

25.6.1 Application Requirements

Part A

The following applicants/recipients are required to apply for Medicare Part A:

• An individual 64 years and 9 months of age or older who is either a US Citizen or LPR who has been in the US for 5 years or more.

Note: Non-citizens eligible for Restricted Scope are not required to apply for Medicare. These individuals could qualify for free Part A if they have paid into SSA the required quarters or are eligible to receive benefits from a spouse/parent (alive or deceased) who paid into SSA for the required quarters.If an undocumented individual on restricted scope is approved for Medicare Part B, the premium must be entered as an expense on the Collect Medical Expense Detail window. Entering the expense on the Collect Medicare Expense Detail window will not allow the deduction in the budget.

• Any individual applying for MC on the basis of blindness or disability (e.g., DDSD approvals).

• Any individual receiving RSDI or Railroad Retirement (RR) disability payments.

Exception: Individuals who have received RSDI or RR disability benefits for less than 24 months are not eligible for Medicare Part A and are not required to apply for it.

B = Wife

D = Widow



These individuals will automatically become eligible for Medicare in the 25th month of receipt.

• Any individual receiving dialysis-related health care services.

• Any individual who has paid into SSA for the required quarters.

• Any individual eligible to receive benefits from a spouse/parent (alive or deceased) who paid into SSA for the required quarters.

• Any person applying for MC as a Qualified Medicare Beneficiary must apply for Conditional Medicare Part A if they don't already have it. [Refer to “Qualified Medicare Beneficiary (QMB) Program,” page 25-19].]

25.6.2 Acceptance

Insured individuals receive Part A without paying monthly premiums. However, those uninsured individuals who would only be eligible for Medicare Part A if they paid a premium are not required to accept Part A benefits.

The following applicants/recipients are required to apply for Medicare Part B:

• Individuals who are applying for Medi-Cal on the basis of being aged.• Individuals who are applying for Medi-Cal on the basis of blindness or disability,

Note:Note:These individuals will automatically become eligible for Medicare in the 25th month of receipt. When verification of the beginning month of receipt of RSDI or RR disability is obtained, the EW must set up a case alert indicating the 25th month to begin the Part B Buy-In process.

• Individuals receiving dialysis-related health care services.

25.6.3 CalWIN

For those individuals who must apply for Medicare, the Collect Individual Benefit Detail window must be completed to indicate in CalWIN that the client has applied or was referred to SSA; otherwise, the individual will fail in CalWIN. Do NOT complete the Collect Medicare Expense Detail window unless the client is actually receiving, or conditionally eligible for Medicare Part A and/or Part B.



25.7 Verifying Application for Medicare

25.7.1 SCD 169 - Refer to Apply for Medicare

The EW may use the “Referral to/from Social Security” (SCD 169) to verify application for Medicare or to refer aged/disabled US Citizens and LPRs who meet the 5 year residency requirement.

• The EW must clearly note the purpose of the referral by checking box III, “Application for Medicare.”

• The Social Security Administration will respond on the SCD 169 with Medicare eligibility information.

Note:

SPLTR 744 “Requirement to Apply for Medicare” should be sent along with the SCD 169.



25.7.2 Timeframes

Verification of Medicare approval or denial must be submitted within 60 days of the date that the EW notifies the applicant/recipient of the requirement to apply. When application has been made, but eligibility for Medicare has not been determined within 60 days, the EW must:

• Verify that the client has actually applied for Medicare.• Advise the customer that verification must be submitted within 10 days of the date the customer

receives notification of Medicare eligibility or ineligibility.

25.7.3 Client Refusal

If the applicant/recipient refuses to apply for Medicare or refuses to provide verification of application, Medi-Cal benefits must be denied or discontinued.

Exception:Exception:

Regulation only requires individuals to apply for other health coverage (including Medicare) when there is no cost involved to obtain it. If client has a SOC, they must not be discontinued for failure to apply for Medicare. [Refer to “Medicare Part B Enrollment Requirement”, page 25-12]

25.7.4 Disenrollment

A recipient who is eligible for Medicare must not dis-enroll from Medicare once Medi-Cal eligibility is established.

Should this occur, Medi-Cal benefits must be denied or discontinued. Medi-Cal eligibility must not be restored until verification of reapplication for Medicare is submitted.

25.7.5 Verifications

Medicare eligibility must be verified by viewing any of the following:

• A Medicare card.

• A Social Security award letter showing the recipient’s MBI/HIC.

• An explanation of Medicare benefits form (BEOMB), issued by Medicare, showing Medicare payment for a medical bill.

• A bill for Medicare Part A or Part B.

• Other correspondence from the Social Security Administration which verifies Medicare eligibility.


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/medical/mcchap25.pdf#page=12




25.8 Enrollment Periods

The following information is a discussion of Social Security Administration's enrollment periods. This information does not change the MC requirements for certain individuals to apply for Medicare [Refer to “Individuals Required to Apply for Medicare,” page 25-5]]. In general, there are two periods of time during which a person may enroll in Medicare. An individual can enroll in Medicare during his/her initial enrollment period (IEP), or during the general enrollment period (GEP).

25.8.1 Initial Enrollment Period

The initial enrollment period (IEP) is the period of time when an individual can first apply for Medicare. There are different IEPs for different categories of people. The following is a list of the IEPs for individuals age 65, aged Non-citizens who meet their 5 years U.S. residency, and other individuals who are Medi-Cal eligible. Individuals in other special situations who have Medicare questions should be referred to Social Security Administration. EWs are encouraged to advise clients to apply for Medicare benefits during their IEP.

Individuals Age 65

The IEP for individuals age 65 is 3 months before turning age 65 until 3 months after turning age 65.

Aged Non-citizens Who Meet Their 5 Years U.S. Residency

The IEP for aged non-citizens who meet their 5 years U.S. residency is 3 months before the month of their 5th anniversary (of continuous U.S. residency) until 3 months after the month of their 5th anniversary (of continuous U.S. residency).

Individuals Eligible for Medi-Cal

For Medi-Cal recipients who are aged, the IEP for Medicare Part A is the same seven-month period as defined above.

For all Medi-Cal recipients, the IEP for Medicare Part B is not limited to any defined enrollment period, due to the State Part B Buy-In agreement. The enrollment period for Part B is when an individual becomes Medi-Cal eligible and Buy-In takes place.

25.8.2 General Enrollment Period

The General Enrollment Period (GEP) is the period of time from January through March of each year.



• Individuals who do not enroll for Medicare benefits during their IEP can sign up during this general enrollment period. Medicare benefits are effective in July of the same year.

• Occasionally the Social Security Administration will extend the GEP.

25.9 Medicare Coding

The Medi-Cal record of an individual has Medicare eligibility coding which produces Medicare status codes on the INQM [Medi-Cal/CMSP Information] screen on MEDS. These codes:

• Identify Medicare Part A and/or Part B coverage for eligible Medi-Cal recipients.• Produce a Medicare eligibility message on the providers POS device indicating that Medicare

must be billed prior to billing Medi-Cal.

Note:

EWs can view the message on the “MEDS Online POS Inquiry” (MOPI) screen.

25.10 MC Recipients with Medicare andOther Health Coverage (OHC)

Medi-Cal recipients who have Medicare and supplemental (Medigap) insurance policies (OHC) have the option of suspending their Medicare supplemental insurance coverage premiums for up to 24 consecutive months while they are Medi-Cal eligible.

Medi-Cal recipients who are interested in suspending their Medicare supplemental insurance policies must contact the private insurance company.

25.10.1 Client and EW Action

Once the Medigap premiums are suspended, Medi-Cal recipients with Medicare must immediately contact their eligibility worker.

The EW must take the following action when they are contacted:

Table 25-1: EW Action

Step Action

1. Remove the amount listed in the Premium field on the Collect Health Care Coverage Detail window.



25.11 Medicare Buy-In

Part A

The State will pay (Buy-In) the Medicare Part A premium for Qualified Medicare Beneficiaries (QMBs), who qualify for it only by paying a premium. [Refer to “Qualified Medicare Beneficiary (QMB) Program,” page 25-19] for QMB eligibility requirements.]

Part B

Buy-In refers to the arrangement through which the State Department of Health Care Services (DHCS) uses Medi-Cal funds to pay the monthly premiums of Medicare Part B for qualifying Medi-Cal recipients, including certain SSI/SSP recipients and ABD-MN individuals. This process ensures that Medicare shares a major portion of the recipient's medical expenses. By paying Medicare Part B premiums, DHCS obtains the maximum amount of federal money for the health care costs incurred by Medicare/Medi-Cal recipients. Buy-In is extremely important in reducing the State's total Medi-Cal costs.

25.11.1 Individuals Eligible for Buy-In

Individuals eligible for Medicare Part B and MC with no SOC or MC with SOC that has been met or are eligible for QMB/SLMB/QI-1 are entitled to State Buy-In.

25.11.2 Individuals Ineligible for Buy-In

Undocumented Non-citizens and medically indigent adults/children are not eligible for a Medicare Buy-In.

25.11.3 Individuals With SOC

Department of Health Care Services (DHCS) stopped paying Medicare Part B premiums for Medicare eligible MC recipients who have a Share-of-Cost (SOC) unless the SOC is met on a monthly basis effective April 1, 2011.

Individuals who have SOC will be eligible for the Part B buy in after the full SOC is met or certified.

2. Send a required ten-day notice if this change results in a share of cost (SOC).

Table 25-1: EW Action

Step Action



Individuals who are ineligible for the state buy in of Part B premium may choose to continue receiving their Part B coverage by paying the monthly premium. Those who are receiving Social Security benefits will have their Part B premium deducted from their monthly checks.

Voluntary Disenrollment

Individuals with a SOC who want to voluntarily disenroll from Medicare Part B must contact the Social Security Administration to disenroll. Once disenrolled, the Medicare Part B premium must no longer be allowed as an income deduction.

Note:

Disenrollment from Medicare Part B affects eligibility for Medicare Part D prescription drug coverage. Those who disenroll will end up paying for drug prescriptions since MC no longer covers prescription drugs for dually MC and Medicare eligibles (including those individuals who voluntarily disenroll).

Medicare Part B Enrollment Requirement

Individuals with a SOC are no longer required to apply for Medicare Part B as a condition of MC eligibility, unless the individual is also MSP eligible. This is due to the fact that regulations only require individuals to apply for other health coverage (including Medicare) when there is no cost involved to obtain it.

Income Deduction

Individuals who are ineligible or were dropped from buy in and continued to keep their Part B coverage by paying the monthly premium must be allowed the Part B premium as an income deduction in their MC budget to determine the SOC.

If allowing the Part B premium as an income deduction makes them eligible for the Aged and Disabled Federal Poverty Level (A&D FPL) program, the state will pay their premium for the month impacted retroactively. The client will be reimbursed for that month through their SSA benefit retroactively. When this happens, the client is caught in a “revolving door.”

Example:

In March 2011, an aged client had a SOC of $90.00. The state stopped the buy in effective 4/1/11. The client received his reduced SSA check on 5/1/11. The client called the EW to report the change and provided verification of his SSA check showing a reduction due to Part B premium payment. The EW must revise the May MC budget allowing the $96.40, Part B premium as an income deduction. After the deduction, the client is eligible for A&D FPL program which qualifies him for state buy in. Since the client is now eligible for zero SOC MC, the state will start initiating buy in again and the “revolving door” continues.



Budgeting

The following policies apply only for individuals who have a SOC and are ineligible for QMB/SLMB/QI-1:

• There is no requirement to check Part B buy in either on MEDS or with clients on a monthly basis.

• The EW must not anticipate or predict that Part B buy in will be in effect. This includes individuals who are caught in the “revolving door.”

• Whenever there is a “revolving door” impact on the client’s SOC, it is to the client’s advantage to continue to allow the Part B premium deduction in the budget as the end result will be the same, which is eligibility for buy-in.

If the client is not receiving the full SSA amount as shown on the Income and Eligibility Verification System (IEVS), the EW must not automatically assume that the client is paying Part B premium. Other deductions may possibly include Part C/D premiums, child support or overpayments. It is important that EWs carefully review the information on IEVS, verification provided by the client and/or confirm with the client to determine the types of deductions being taken from the client’s SSA check.

Intake

For new applications, the intake EW must no longer assume that Part B buy-in will take effect within two months from the date of approval for individuals with a SOC who are ineligible for QMB/SLMB/QI-1.

Continuing

As the EW becomes aware (e.g., client reported) that the client was dropped off from the Part B buy-in due to the state’s non payment of premium, the EW must revise the budget retroactively beginning the month the client’s SSA check is reduced.

25.11.4 Buy-In Procedures - Budgeting

Initiating Buy-In

To ensure statewide uniformity in establishing Buy-In and to eliminate related QC errors, the EW must initiate the Buy-In process.

• The EW initiates Buy-In by entering the client's medicare information (including the MBI/HIC) in the Collect Individual Benefit Detail and Collect Medicare Expense Detail windows. Entering only the Medicare Premium does not initiate Buy-In.

• Timeliness and accuracy in reporting the MBI/HIC number is essential, as late or erroneous reporting results in increased problems, customer complaints, and a possible loss of benefits.



• It is crucial that Buy-In be accomplished quickly to avoid potential hardship. Clients who receive no RSDI or RR benefits must otherwise pay the cost of their Medicare Part B premiums to Social Security Administration.

Buy-In Effective Date

The EW must assume there is no break in Buy-In coverage when the recipient has had no break in Medi-Cal eligibility.

The EW must assume Buy-In and budget the gross RSDI amount in the following cases:

• When a recipient changes Medi-Cal status from SSI/SSP to ABD-MN, unless there has been a discontinuance of Medi-Cal benefits for one month or more.

• When changing aid codes within the MN category (i.e., 66 to 16).

• When the individual changes county of residence (inter-county transfer).

EXAMPLE #1:

The applicant signs the SAWS 1 and is approved for eligibility within the same month.

If the customer signs the SAWS 1 in September and eligibility is authorized in CalWIN in September, Buy-In is anticipated in November. CalWIN will no longer allow the medicare premium in the December budget.

EXAMPLE #2:

The date of approval is not within the first month of eligibility.

An applicant, over age 65 and currently eligible for Medicare, applies for MC in July and is not approved/authorized in CalWIN until September (with begin effective date of July). Buy-In must be anticipated in November. CalWIN will no longer allow the medicare premium in the December budget.

Premium Reimbursement

The recipient will receive a retroactive check/reimbursement to their direct deposit bank account for the Medicare premiums which he/she paid in the months covered by the Buy-In agreement.

Note:

These SSA reimbursements for the Medicare premium are exempt as a lump sum RSDI payment but counted as property in the month of receipt.



Verification

Buy-In must be verified (e.g., MEDS [INQB] screen, IEVS, etc.).

SOC Adjustment

The recipient is entitled to a SOC adjustment when Buy-In has been anticipated, yet did not occur.

[Refer to “Change in the Share of Cost (SOC),” page 27-2]

25.12 MEDS [INQB] Screen

The INQB [Buy-In and Bendex Information] screen is available through the MEDS system to help EWs determine the Buy-In status of MC recipients.

The code in the [STATUS] field on the [INQB] MEDS screen indicates the Buy-In status: accretion pending (i.e. 61), accretion accepted (i.e. 1161), accretion rejected (i.e. 2100). [Refer to User’s Guide to State Systems Handbook, “BUY-IN-ELIG-CD,” page 12-17 for a complete description of Buy-In Status codes.]

25.13 Buy-In Alerts/Messages

The EW is responsible for correcting Buy-In and/or Medicare coding problems. Medicare Buy-In alert messages are sent to the EW advising of any potential Buy-In problems. Messages are generated only for currently active recipients.

Upon receipt of a Buy-In alert, EWs must review the Buy-In information on the INQB screen. [Refer to User’s Guide to State Systems Handbook, “County Eligibility Worker Alerts: 0001-1999,” page 8-1; “County Eligibility Worker Alerts: 2000 - 3999,” page 9-1; “County Eligibility Worker Alerts: 4000 - 8999,” page 10-1; “County Eligibility Worker Alerts: 9000 - 9999,” page 11-1; and “County Eligibility Worker Alerts/Daily Alerts,” page 7-1; for specific instructions in how to correct an alert.]

25.14 State Medicare Buy-In Problem Form

EWs must first ensure Buy-In problems are resolved after correcting discrepancies of the client’s data and the client has accurate eligibility in MEDS and CalWIN. If necessary, submit an SCD 1296.

The EW must review the problem and their efforts to correct it with their supervisor, before completing an online fillable State Medicare Buy-In Form.


https://www.dhcs.ca.gov/services/Pages/TPLRD_MOU_cont.aspx


The online fillable State Medicare Buy-In Problem Form is used to correct Buy-In problems after the EW’s corrective actions are unsuccessful.

25.14.1 Situations Requiring the Use of the State Medicare Buy-In Problem Form

The State Medicare Buy-In Problem Form must be used by the EW to report specific Buy-In problems including, but not limited to, the following situations:

• When an individual is inadvertently dropped (deleted) from Medicare Buy-In.

• To advise DHCS a recipient is entitled to Buy-In when activity (accretion) has not been confirmed 2 months after the Medical approval date.

• To change the MBI/HIC number on the MC record if pending or active (accreted) status is shown on the MEDS INQB screen.

25.14.2 EW Action

Before submitting an online fillable State Medicare Buy-In Problem Form to the Medicare Premium Payment (Buy-In) Program, EWs must first:

• Review the Buy-In information on the INQB screen. • Evaluate the [STATUS] fields, and• Evaluate the effective date of Part A/B [EFF-DATE], and the last Bendex change date

[LAST-BENDEX-CHG].

• Review the Medicare code [MEDICARE] on the INQM screen.

• Make corrections through the CalWIN/MEDS on-line processes. [Refer to User’s Guide to State Systems Handbook, “County Eligibility Worker Alerts: 2000 - 3999,” page 9-1; “County Eligibility Worker Alerts: 4000 - 8999,” page 10-1; and “County Eligibility Worker Alerts: 9000 - 9999,” page 11-1 for specific instructions in how to correct Buy-In problems.]

• Obtain the EW Supervisor approval to send an online fillable State Medicare Buy-In Problem Form if repeated attempts to correct the problem have failed.



25.14.3 Completing the State Medicare Buy-In Problem Form

For the Medicare Premium Payment (Buy-In) Program to successfully resolve a problem case, adequate details are needed on the State Medicare Buy-In Problem Form. The following information must be thoroughly completed:

• Section A: County or Agency Representative Information (EW’s contact information including the EW’s email address).

• Section B: Beneficiary or Client Information.• Section C: Problem Reference by selecting an appropriate Buy-In Problem Quick Reference from

drop-down menu and describe a specific detailed problem and the change being requested under Remarks section (200 character limit.) If necessary, the EW may attach verifications, documents or files.

EWs will receive a reply via email from the Buy-In Unit within 24 to 48 business hours after submitting an online State Medicare Buy-In Problem form. If no response received within 48 hours, EWs should contact the Buy-In Unit by a secured email or phone.

25.14.4 Contacting Medicare Buy In Unit

The EW may contact DHCS to report Buy-In problems either by:

• Completing the State Medicare Buy-In Problem Form on the TPL web page: http://www.dhcs.ca.gov/services/Pages/TPLRD_MOU_cont.aspx

• Sending a Secure e-mail to [email protected]

• Calling Buy-In Unit at (916) 750-3563

25.14.5 EW Follow-Up

After sending an online fillable State Medicare Buy-In Problem Form to notify DHCS to resume Buy-In, the EW must:

• Adjust any overstated SOC for those months where the customer has met their reporting responsibilities in a timely manner. [Refer to “Share of Cost,” page 27-1]

• Anticipate completion of the Buy-In process to occur in the second month after the State Medicare Buy-In Problem Form has been sent to DHCS.

• Monitor the [INQM] and [INQB] screens to ensure that Buy-In occurs.


Update #20-02

Medi-

25.15

MC Bu

ProProperty Reserve Limit

Effective Date of buy‐in

ABD(ReMC

1 = $66002 = $9910

Part B:3rd month after approval

SSI 1 = $66002 = $9910

Part B:Month approved (cash)

QM 1 = $66002 = $9910

Parts A & B:Month after approval if on Part A; or July 1 when Part A usually starts

SLM 1 = $66002 = $9910

Part B:Month of Approval

Page 25-18

Cal 25. Medicare Coverage

MC Buy-In Chart

y-In Chart

Table 25-2:

What MC Pays

Medicare Part A(Hospital Ins.)

Medicare Part B(Doctor’s Medical Ins.)

gramScope of MC Benefits

Prem. Deduct. Co‐Ins. Prem. Deduct Co‐Ins Income Limit

-MN gular )

Full X(If enrolled in Part A)

X(If enrolled in Part A)

X X X Share of Cost based on maintenance need, unless in a% program

/SSP Full X(If enrolled in Part A)

X(If enrolled in Part A)

X X X Various levels depending on circumstances

B Limited X X X X X X 100% of Federal Poverty Level

B Limited X 120% of Federal Poverty Level

Update #20-02

Medi-

25.16

• QM Qualified Low-Income Medicare Be Application” (MC 14 A) is not req

Eligibilit MEDS.

25.16.1

The QM ome Qualified Medicare Benefic

QI-1 1 = $66002 = $9910

Part B:Month of Approval

QD 1 = $66002 = $9910

Part A:Month Approval

ProProperty Reserve Limit

Effective Date of buy‐in

Page 25-19

Cal 25. Medicare Coverage

Medicare Savings Programs (MSP)

B, SLMB and QI programs are referred to as “Medicare Savings Programs.” Completion of the “neficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individuals uired to be eligible for QMB.

y for all MSP can be viewed on one of the Special Program screens, [INQ1], [INQ2], or [INQ3] in

Qualified Medicare Beneficiary (QMB) Program

B Program requires State to pay the Medicare premiums, deductibles and coinsurance of low inciaries.

Limited X 135% of Federal Poverty Level

WI Limited X 200% Federal Poverty Level

Table 25-2:

What MC Pays

Medicare Part A(Hospital Ins.)

Medicare Part B(Doctor’s Medical Ins.)

gramScope of MC Benefits

Prem. Deduct. Co‐Ins. Prem. Deduct Co‐Ins Income Limit


Note:

Coinsurance is the amount Medicare charges the patient. It is based on the Medicare approved rate for a medical service.

General Eligibility Criteria

To be eligible as a QMB, a person must:

• Be eligible for Medicare Part A, hospital insurance.

• Be within the property limit.

• Have income at or below 100% of the Federal Poverty Level (FPL). [Refer to Chart Book, for current QMB income limits.]

• Be a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits if he/she were applying for regular Medi-Cal.

Note: An undocumented Non-citizen or an amnesty Non-citizen who would only get restricted Medi-Cal benefits is not eligible for QMB.

• Be otherwise eligible for Medi-Cal (for example, meet California residency and verification requirements).

Note: Application or eligibility for MC is not required to qualify and be eligible for QMB.

Two Basic Groups of QMBs

There are two basic groups of QMB eligibles; “QMB Only” recipients and “Dual Eligibles”. The description of each group and the benefits received are described in the following chart:

Table 25-3:

Applicant Type Medi‐Cal Benefits Advantages

QMB Only



When to Evaluate for QMB

EWs must evaluate QMB eligibility when:

• An applicant is applying for QMB.

• A Medi-Cal applicant is aged, blind or disabled and has Medicare (or is potentially eligible for Part A).

• An SSI/SSP recipient applies for QMB and has Part B Medicare and no Part A; or, pays a premium for Part A.

• An SSI/SSP recipient who already has Part A free.

• An aged, blind or disabled Medicare eligible person is included in a CalWORKs cash household or is applying for IHSS.

Aged, blind or disabled (ABD) individuals who:Are not eligible for full-scope Medi-Cal due to excess property, or Are eligible for full-scope Medi-Cal but choose to apply for only QMB.

Receive a MC BIC.POS Device message will indicate that MC coverage is only for MEDICARE DEDUCTIBLES AND COINSURANCE”. Covers Medicare:

• Premiums (Part B for all QMBs and Part A for those who do not already get Part A free.)

• Deductibles.

• Coinsurance, based on Medicare approved rate.

Higher property limits. NOTE: EWs should encourage full-scope Medi-Cal whenever possible, as regular Medi-Cal covers more than QMB, including: Medicare Part B premium (thru Buy-In), Medicare deductibles and coinsurance. Additional medical services; including, but not limited, to: • Outpatient prescriptions and eye

glasses. • Custodial and skilled nursing

facility level of care.

Dual Eligible QMBs

Qualify for full MC, Medicare Part A, and have income at or below the QMB income limit, including:

• Some ABD-MN individuals.

• SSI/SSP recipients with or without “free” Part A.

• Certain IHSS or CalWORKs recipients.

Receive their regular MC; however, the QMB aid code is reported to MEDS and can be viewed on one of the Special Program Screens.POS Device Message (on MOPI MEDS screen):“...1st SPECIAL AID CODE: 80 PART A, B... PART A, B AND D MEDICARE COVERAGE W /MEDICARE ID #_____ MEDICARE PART A AND B COVERED SVCS MUST BE BILLED TO MEDICARE BEFORE BILLING MC...”

• The state receives federal funding for Buy-In.

• Once enrolled in Medicare Part A, individuals have a slightly wider choice of hospitals and nursing homes.

• Medi-Cal pays the Part A premium for those individuals who do not receive it free.

Table 25-3:

Applicant Type Medi‐Cal Benefits Advantages



• A redetermination is due.

• A person is eligible for Medicare Part A and there is a change in income or a change in the QMB income limits.

Effective Date of Eligibility

There is no retroactive eligibility for QMB. Aid code ‘80’ displays on one of the Special Program Segment in MEDS once QMB program is approved.

For those applicants/recipients that already have Medicare Part A, eligibility begins the first of the month following the date that the EW actually determines and authorizes QMB eligibility in CalWIN.

Note:

This requirement is due to the State Buy-In agreement with the Social Security Administration.

QMB Examples

Example 1 QMB OnlyA customer applies for QMB January 15. The EW processes the application and clears eligibility on February 8. The effective date of QMB eligibility is March 1. However, it will take 2-3 months for Buy-In to take place. Once Buy-In is activated, the customer will be reimbursed for the Medicare Part A and/or Part B premium back to March.

Example 2 Dually EligibleA customer applies for Medi-Cal January 31. The EW determines on 3/2 that there is Medi-Cal eligibility effective January 1 and that the client is under the QMB income limit. QMB eligibility begins April 1.

Example 3 Approved Month Following the ApplicationThe customer applies and clears eligibility in March, but does not approve the case until 4/15. QMB eligibility begins April 1, as the EW cleared eligibility in March.

Pre-Approved QMBs

Individuals who meet QMB eligibility criteria, but who must apply for Medicare Part A during the “general enrollment period” from January to March each year (because they did not apply during their “initial enrollment period”), are “pre-approved QMBs”. Their QMB benefits will actually begin in July 1.



For “pre-appoved QMBs” with conditional Medicare part A (PAYOR status ‘Z99’ on INQB MEDS screen) cases, EWs should use the MC application date as the Part A Approval Date in the Collect Medicare Expense Detail window to be able to approve QMBs in CalWIN.

Example:

Mrs. Smith applied for “pre-appoved QMB” program on 03/24/2017 with a proof of Conditional Medicare part A approval that she applied in 02/2017 during open enrollment period at Social Security Administration. She met all other eligibility criteria and was approved for “pre-approved QMB” effective April 2017 in CalWIN and with ELIG-STAT ‘891’ on one of the special segments in MEDS. In July 2017, Medicare part A buy-in will be automatically initiated to trigger ELIG-STAT in MEDS updated from ‘891’ to ‘301’ that indicates Mrs. Smith’s QMB benefit will start on 07/01/2017.



Ineligible QMBs

Individuals applying between April and December who do NOT have Medicare Part A, must be referred to SSA to apply for conditional Part A. If SSA does not allow them to apply for conditional Part A, deny the application.

Note:

If they appear to meet the other QMB criteria, advise them to apply for conditional Part A at SSA during the next general enrollment period (January-March), and reapply for QMB.

Verification of Medicare Part A

Medicare Part A benefits must be verified. Verification includes any of the following:

• The Medicare card (“Hospital insurance” indicates Part A coverage).

• An SSA Medicare Award Letter.

• A print of the MEDS [Buy-In Bendex Information] INQB screen showing Part A entitlement.

• Other correspondence from SSA.

• Verification from IEVS (Applicant System).

“Conditional” Medicare Part A

Those individuals who are not receiving Part A but who would be eligible for it by paying a premium may sign up for “conditional” Part A Medicare.

• This means the client is requesting Part A Medicare only if the state pays the premium. They will not be charged a premium if ineligible for QMB.

• Conditional enrollment must take place between January 1 and March 31, or during the individual's initial enrollment period when he/she first becomes entitled to Medicare.

MC 176 QMB-3

QMB applicants are to be referred to their local Social Security Administration office with a “Qualified Medicare Beneficiary (QMB) Referral” (MC 176 QMB-3) when:

• It is necessary to apply for conditional Medicare Part A, or• They state that they have Medicare Part A or that they think they are eligible for it, however they

do not have any verification.



Note:

Social Security uses the “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SCD 176 QMB) in the SSI QMB Mail-In Referral procedure. This procedure allows Social Security to refer by mail all SSI/SSP recipients who are “conditionally” eligible for Medicare Part A to Social Services to apply for QMB. [Refer to “SSI QMBs,” page 25-29].]

QMB applications must be recorded according to the information provided on the MC 176 QMB-3 or other verification from the Social Security Administration as follows:

Table 25-4:

If... Then...

The QMB applicant is conditionally eligible for Medicare Part A (is applying for Part A during the general enrollment period)

Approve QMB. Benefits will actually begin July 1.

Follow up immediately to ensure that:• A MEDS QMB record has been established on one of

the Special Program Segment [INQ1], [INQ2], or [INQ3] screen and

• A pending accretion [STATUS] code is showing on the Buy-In and Bendex Information [INQB] screen.

Follow up in August to verify Medicare approval and:• Review the MEDS [INQM] and [INQB] screens to

determine if the Buy-In accretion was successful.

• Take corrective action if Buy-In rejection occurs.

The QMB applicant is eligible for Medicare Part A Approve QMB. Eligibility is effective whichever of the following dates is later:• The Medicare Part A effective date, or • The first of the month following the date the EW

determines QMB eligibility.

The QMB applicant is not eligible for Medicare Part A or must reapply during the general enrollment period

Deny/discontinue QMB.

QMB Property Determination

The net non-exempt property of a QMB applicant/recipient prior to 1/1/2010 cannot exceed twice the Medi-Cal property limit. As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI).

[See Chart Book “Medicare Savings Program (MSP) Income Limits and Property Limits,” page 5-9]



Note:

The QMB property rules contained in this section also apply to the Specified Low-Income Medicare Beneficiary (SLMB) Program and the Qualifying Individual (QI-1) Program.

The “QMB/SLMB Property Worksheet, Adult” (MC 176P QMB/SLMB-A) is used (optional) when determining eligibility for the QMB/SLMB/QI Only programs.

If the QMB applicant/recipient is eligible for Medi-Cal from another program (e.g., ABD-MN, SSI/SSP) the QMB property limit is met.

Rules

The EW must follow the rules below when determining QMB property eligibility for the following groups of people:

Individuals (Adults) with no Spouse (age 18 and over)

First determine property under Non-MAGI Medi-Cal rules. (MFBU rules apply.) The individual is dually eligible if equal to or under the Medi-Cal property limit.

If over the Non-MAGI Medi-Cal property limit, then the following apply:

• Count only the resources of the QMB/SLMB/QI applicant.• Do not consider the property of other family members in the home.• The applicant is QMB/SLMB/QI property eligible if equal to or under twice the Medi-Cal property

limit for one.

Individuals Ages 18-21

A QMB/SLMB/QI applicant age 18-21 is considered an adult for a QMB (or SLMB) property determination, even though he/she would be treated as a child for Non-MAGI Medi-Cal (e.g., is a blind or disabled MN person who is living in the home of a parent and is currently in school).

• Determine property under Non-MAGI Medi-Cal rules if applying for Non-MAGI Medi-Cal. (MFBU rules apply.)

• For QMB/SLMB/QI, count only the resources of the 18-21 year old and his/her spouse, if any.

Couples, Both Spouses in Home

These rules apply whether one or both spouses are applying for QMB/SLMB/QI.

• A married person under age 18 is considered to be an adult for QMB/SLMB/QI.



• If only one spouse is receiving Medi-Cal from another program, the QMB/SLMB/QI property limit is met for both spouses.

• First determine property limit. (MFBU rules apply.) The individual (or couple) is dually eligible if their property is equal to or under the LIS property limit.

Child, Under 18

Rarely will a child under age 18 be eligible for QMB/SLMB/QI, as a child can only be eligible for Medicare if in need of maintenance kidney dialysis or a kidney transplant.

Contact the Medi-Cal Coordinator for instructions. The property determination is different from the instructions outlined above.

Other Requirements

QMB Only applicants/recipients must meet all other Medi-Cal Program requirements, including:

• Completion of all appropriate Medi-Cal forms (MC 13, Rights and Responsibilities, etc.)

• Providing any necessary verifications. (IEVS is required.)

• Completing an annual redetermination.

• Reporting any changes within 10 days. (Income reports are not required for ABD-MN households.)

• Maintaining California residency.

Notices of Action

EWs are required to determine the level of benefits each Medi-Cal applicant is entitled to, explain the options (including spenddown), and issue benefits and the appropriate notices of action.

Approvals

A QMB Approval NOA must be issued when:

• A person is eligible for QMB only.

Note: Send the appropriate denial for regular Medi-Cal benefits (e.g., excess property).

• A person is otherwise eligible for QMB and is “Preapproved” pending confirmation of eligibility for Medicare Part A.



• When an ABD-MN eligible person who is paying his/her own Medicare Part A premium is income eligible for QMB, and is therefore entitled to State Buy-In of the Part A premium.

A QMB Approval NOA must not be issued when an individual is dually eligible and receives Medicare Part A free. In this situation the client receives no additional benefits. However, the State will receive federal funding for Buy-In.

Denials/ Discontinuances NOA

Denial and discontinuance NOAs are automatically generated when the QMB budget computation determines that the client is not income eligible for QMB.

A QMB denial or discontinuance must be sent when:

• A person has applied for, or received, QMB Only and is found ineligible. (e.g., excess income, property, not a resident, etc.)

• A “pre-approved” person is found ineligible for Medicare Part A.

• An ABD-MN applicant/recipient is not eligible for Buy-In of his/her Part A premium payment due to excess income.

A QMB denial or discontinuance NOA is NOT required for dually eligible ABD-MN applicants/recipients who have free Medicare Part A coverage.

Erroneous Discontinuance

The QMB eligibility must be restored back to the date the QMB eligibility was erroneously discontinued. Although the QMB does not provide retroactive eligibility, eligibility can and must be reinstated for past months (there should not be any break in aid) when a client was eligible.

In order for QMB buy-in to be reinstated, the MC Buy-In unit must retroactively pay for all Medicare premiums in arrears to Social Security Administration. Once the QMB eligibility is restored on MEDS, the State’s Medicare Buy-In system will process a Medicare Part A buy-in transaction. In order to ensure that the Medi-Care buy-in transaction is processed correctly, the EW can submit an online State Medicare Buy-In Problem Form to DHCS, Medi-Care Buy-In unit.

ICTs

QMB Only

QMB Only cases follow current eICT procedures. [Refer to “Inter County Transfers,” page 7-9]



SSI QMBs

The EW in the old county will receive an alert (CWEA) when the SSI county of responsibility changes. Initiate an eICT to the new county when the MEDS alert is received.

SSI QMBs

SSI/SSP recipients have full Medi-Cal coverage. However, they may benefit from Buy-In of their Part A premium if they are QMB eligible and:

• They are paying a premium for their Medicare Part A benefits, or• They don't have Medicare Part A because they cannot afford to pay the premium.

Medicare Part A benefits may provide them with a slightly wider choice of hospitals; otherwise, there is no benefit.

Application Forms

An SSI/SSP recipient has already been determined eligible for and is receiving MC. Therefore, when an SSI/SSP recipient applies for QMB, no new application is required.

SSI QMB Mail-In Referral Procedure

The following SSI QMB Mail-In Referral procedure has been established with the Santa Clara County Social Security Field Offices.

Table 25-5: SSI QMB Mail-In Procedure

Stage Who Action

1. Social Security Completes an “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SCD 176 QMB) for each SSI recipient applying for “conditional” Medicare Part A.

Mails the SCD 176 QMB directly to the Assistance Application Center (AAC) as an application for QMB MC.

2. AAC Mail Room Forwards the SCD 176 QMB to Clerical.

3. Clerical Forwards the SCD 176 QMB as follows:

if there is... then the SC 176 QMB is sent to...

An active case record in any aid type, The supervisor of the current case carrying EW.

No active case record, The appropriate intake office.

4. Receiving District Office

Ensures that the application is ID’d and assigned timely.



Phone/Walk-in Applications

SSI/SSP recipients who are not referred by Social Security to the county by mail with a SCD 176 QMB may apply for QMB by phone or in person.

Application Requirements

• A face-to-face interview is not required.

• A property determination is not required.

• An income determination is required. [Refer to “Income Determination,” page 25-31].]

• Verification of “conditional” Medicare Part A is required. [Refer to “Verification of Medicare Part A,” page 25-31].]

• An SSI QMB applicant must receive a QMB approval or denial NOA.

5. EW Determines SSI QMB eligibility.

• Use the [INQX] MEDS screen to verify and determine income eligibility.

• Use the SCD 176 QMB as verification of “conditional” Medicare Part A.

The SCD 176 QMB and copies of MEDS screens used to verify income and Medicare eligibility must be retained in the case file.

Approves/Denies the QMB application and issue the appropriate approval/denial Notice of Action (NOA).

If approved, completes the appropriate follow-up action.

• Ensures an active QMB record is established on one of the MEDS Special Program Segment [INQ1], [INQ2], or [INQ3] screen.

• Ensures Buy-In accretion is initiated (i.e. “61” in the [STATUS] field on the [INQB] MEDS screen).

• Ensures Buy-In accretion is later added to the Buy-In Program (i.e. “1161” in the [STATUS] field on the [INQB] MEDS screen).

[Refer to User’s Guide to State Systems Handbook, “BUY-IN-ELIG-CD,” page 12-17 for a complete description of the coding found in the [CUR-BUY-IN STATUS] field.]

Table 25-5: SSI QMB Mail-In Procedure

Stage Who Action



Income Determination

EWs must determine the SSI/SSP recipient's net non-exempt income.

SSI/SSP income is exempt.

The [Title XVI-SSI/SSP Information] INQX MEDS screen can be used to verify countable income. Send the MEDS screen to IDM as an income verification.

• If the NET-UNEARN-INC, NET-EARNED-INC and DEEMED-INCOME are equal to or less than the QMB income limit for one, the person is QMB eligible.

• If the total countable income is over the QMB income limit for one, the person is ineligible for QMB.

If the information from the [Title XVI-SSI/SSP Information] INQX screen is not available, use other income verifications and complete the MC 176 QMB/SLMB 2A (or use MACB whenever possible).

Verification of Medicare Part A

The SSI/SSP recipient must verify that he/she has applied for “conditional” Medicare Part A.

• The SCD 176 QMB is used by Social Security to refer an SSI/SSP recipient to Social Services by mail to apply for QMB. This form serves as verification that the SSI/SSP recipient has applied for “conditional” Medicare Part A.

• The MC 176 QMB-3 is used to refer an SSI/SSP recipient who has filed an application for QMB, but has not yet filed an application for Medicare Part A to the Social Security Administration to apply for “conditional” Medicare Part A. This referral should only be done after QMB income eligibility is determined.

(1) Mail the MC 176 QMB-3 to the recipient, or issue in person, during SSA's “general enrollment period”, January 1 through March 31.(NOTE: Sometimes SSA extends the general enrollment period.)

(2) Deny the QMB application if SSA states that the person is not eligible for Medicare Part A or that he/she must wait until the next “general enrollment period” to apply.

[Refer to “MC 176 QMB-3,” page 25-24] for additional information about processing the MC 176 QMB-3 and the actions to be taken when SSA verifies the status of Medicare Part A.]

The verification of Part A entitlement (SCD 176 QMB, MC 176 QMB-3 or print of [INQB] MEDS screen) must be filed in IDM.



Redetermination (RDs)

The EW must review MEDS to ensure that the individual is still receiving SSI. Once SSI eligibility is confirmed, only two requirements must be completed by the EW:

1. Reverify the SSI/SSP recipient's net non-exempt income via the [INQX] screen on MEDS. [Refer to “Income Determination,” page 25-31].]

2. Check the [INQ1], [INQ2], or [INQ3] and [INQB] MEDS screens to ensure that QMB eligibility is being correctly reported to MEDS and that verification of Medicare Part A entitlement is on file.

Deny or discontinue QMB if the individual is ineligible for Part A.

Copies of MEDS screens used to verify income and Medicare eligibility must be filed in IDM. No other forms or verifications are necessary for SSI QMB redeterminations.

Discrepancies

Occasionally the EW will receive information from an SSI QMB applicant which is inconsistent with SSI and/or QMB eligibility rules. Although the EW is not required to verify anything beyond income (as recorded on MEDS) and Medicare Part A entitlement, discrepancies in reported information must be resolved.

For example, while an SSI recipient is applying for QMB she tells the EW that she has $20,000 in savings. The EW is to deny QMB for excess property, advising the customer of the QMB property limit. Also, advise the customer that she is over the SSI property limit and that she is to report this information to the Social Security Administration. The EW is not required to contact Social Security and need not follow-up to see that the customer has done so.

Whereabouts Unknown Discontinuance

Prior to discontinuing an SSI QMB case due to returned mail, the EW must review the SSI MEDS record or contact the Social Security Administration via a “Referral of Applicant to SSA” (SCD 169) to determine if the beneficiary has reported a new address to Social Security. If this information is available, the EW must update in CalWIN and the case must not be discontinued due to Whereabouts Unknown. If a new address is not available from MEDS and/or Social Security, the case must be discontinued due to Whereabouts Unknown.

25.16.2 Specified Low-Income Medicare Beneficiary (SLMB) Program

Individuals with income greater than the QMB income limit (100% of the Federal Poverty Level), but less than or equal to the SLMB income limit (120% of the Federal Poverty Level), are eligible for payment of their Medicare Part B premium under the SLMB Program.



Application or eligibility for MC is not required to qualify and be eligible for SLMB.

Effective Date

Eligibility begins the month of application if all eligibility requirements are met. Unlike QMB, clients may apply for 3-month retroactive SLMB.

Benefit

Individuals who apply for SLMB Only get payment (Buy-in) only for their Medicare Part B premium and no other benefits. SLMB does NOT pay for one's Medicare Part A premium, or for Part A and B deductibles and coinsurance.

SLMB only recipients do not receive a MC BIC.

• Once State Buy-In of their Medicare Part B premium begins, the premium will not be deducted from their Social Security check. They will have an increase in their monthly net income.

• SLMB eligibility can be viewed on MEDS, Aid Code '8C' on the Special Program screen.

Individuals who qualify for Medicare Part B may apply for it at any time at the Social Security office. That is, if they refused Part B coverage during their “initial enrollment period” they do not have to wait until SSA's “general enrollment period” (January - March) to apply.

Eligibility Criteria

SLMB applicants/recipients must meet all of the following eligibility criteria:

Medicare Part A

Is eligible for Medicare Part A, either free or they pay for it.

Important:

“Conditional” Medicare Part A applications are not allowed in the SLMB Program. SLMB applicants must be eligible for Part A free or pay their own Part A premium in order to be potentially eligible for SLMB. “Conditional” Medicare Part A only applies to the QMB Program.

Property

The property limit is the same as QMB, prior to 1/1/2010, twice the Medi-Cal property limit:

• $4,000 for one individual



• $6,000 for two individuals

As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI). [See Charts Book “Medicare Savings Program (MSP) Income Limits and Property Limits,” page 5-9

Income

SLMB eligibles must have income in excess of the QMB income limit, but less than the SLMB income limit:

• 110% of the Federal Poverty Limit in 1993 and 1994.• 120% of the Federal Poverty Limit in 1995 and continuing.

Citizen/ Non-citizen Status

SLMB eligibles must be a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits if applying for regular MC. An undocumented Non-citizen who would only get restricted MC benefits is not eligible for SLMB.

Other Requirements

SLMB applicants/recipients must meet all other Medi-Cal Program requirements, including:

• Providing any necessary verifications. (IEVS is required.)

• Completing an annual redetermination.

• Reporting any changes within 10 days. (Income reports are not required for ABD-MN households.)

• Maintaining California residency.

Dual Eligibility

If the client is eligible for MC and has income below 100% FPL, there is no need to set up SLMB as the buy-in for Part B will be initiated once MC eligibility is authorized and the MBI/HIC number is entered.

ABD-MN

EWs must identify SLMB eligibility for those persons who qualify for regular Medi-Cal ABD-MN benefits, have Medicare Part A and B, and whose income is over the QMB income limit but below the SLMB income limit.



These “dual eligibles” (ABD-MN and SLMB) will receive their regular plastic Benefits Identification Card (BIC). However, the SLMB aid code 8C will be reported to MEDS so that the state can receive federal funding for their Part B Buy-In.

SSI/SSPs, SLMB Does NOT Apply

Individuals receiving SSI/SSP are not eligible for SLMB. In addition, EWs will not identify SLMB eligibility for individuals who are receiving IHSS or who are Pickle eligible. (The state already receives federal funding for Buy-In for these individuals.)

When to Evaluate

EWs are required to determine the level of benefits each Medi-Cal applicant is entitled to, explain the options (including spenddown), establish benefits and the appropriate notices of action.

ABD-MN recipients must be reviewed for SLMB “dual eligibility” at the following times:

• At RD, or• When there is a change in income, or• When there is a change in the SLMB income limit. (The SLMB income limit changes annually in

April due to the Federal Poverty Level (FPL) changes.)

NOAs

SLMB Only

Approval, denial and discontinuance NOAs are required for SLMB Only individuals.

ABD-MN and SLMB (Dual Eligibles)

No SLMB NOAs are to be issued to dual eligibles.

25.16.3 Qualifying Individual (QI-1) Program

The Qualifying Individual (QI-1) program pays Medicare Part B premiums. The QI-1 program is a federally funded program which is similar to the QMB and SLMB programs but has a higher income limit.



The following chart provides an overview of the QI-1 program:

Table 25-6: Overview of QI-1 Program

ProgramAid Code

Benefit Provided

Income Limit Program Requirements

Qualifying Individual-1 (QI-1)

8D Buy-In of the Medicare Part B premium.

Income is equal to or more than the SLMB income limit (120% of FPL), but less than or equal to 135% of FPL.

• Eligible for and receiving Medicare Part A. (Conditional Part A does not meet this criteria.)

• Is within the QI property limit. [Refer to “Property,” page 25-37].]

• Not “eligible for MC”. [Refer to “Dual Eligibility,” page 25-38].]

• Is a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits.

• Meets the other MC eligibility requirements (e.g. residency, etc.)

Effective Date

Eligibility begins the month of application if all eligibility requirements are met.

Retroactive QI-1 Benefits

Individuals may apply for 3-month retroactive QI-1 benefits if they were entitled to Medicare Part A and B in those months and are otherwise eligible.

Benefit

Individuals who qualify for QI-1 program are eligible only for payment (Buy-in) of their Medicare Part B premium and no other benefit.

• The QI-1 program pays the full Medicare Part B premium. Once Buy-In of the Part B premium begins, the premium will not be deducted from the recipient’s Social Security check. The customer’s net monthly income will increase.

• The QI-1 program does not pay the Medicare Part A premium, nor for Part A and B deductibles and coinsurance.

• If the client is eligible either for regular Medi-Cal, QMB or SLMB, there is no need to set up QI-1 because the buy-in is already taken care of.

• QI-1 only recipients do not receive a MC BIC.



Eligibility Criteria

Individuals requesting QI-1 must meet all of the following eligibility criteria:

Medicare Part A

The individual must be eligible for Medicare Part A.

Important:

“Conditional” Medicare Part A does not meet this requirement. QI-1 applicants must actually be eligible for and in receipt of Part A in order to be eligible for the QI-1 program.

Property

The property limit is:

• $4,000 for one individual• $6,000 for two individuals

As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI). [See Charts Book “Medicare Savings Program (MSP) Income Limits and Property Limits,” page 5-9]

Resources must be declared on the statement of facts, but the customer is not required to provide verification. EWs must accept the client’s statement. Verification is only required when the client’s statement is inconsistent with information received from another source (i.e., IEVS).

Income

QI-1 eligibles must have income greater than the SLMB income limit (120% of the FPL), but less than or equal to the QI-1 income limit (135% of FPL).

Citizen/ Noncitizen Status

QI-1 eligibles must be a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits if applying for regular MC. An undocumented Non-citizen who would only get restricted MC benefits is not eligible for QI-1.

When to Evaluate

QI-1 eligibility must be reevaluated whenever there is:



• An annual redetermination due, or• A change in income, or• A change in the QI-1 income limits, or• A person becomes ineligible for QMB and SLMB.

Note:

The QI-1 income limits change annually in April when the annual Federal Poverty Level (FPL) is established. The EW must disregard the Social Security Cost of Living Adjustment (COLA) between January 1 and March 31 of each year.

NOAs

Approval, denial and discontinuance NOAs are required for QI-1 applicants/recipients. Ten-day notice requirements apply.

Dual Eligibility

EWs must only establish QI-1-only eligibility. There is no dual eligibility for ABD-MN (zero or share of cost met) and the QI-1 program.

There is dual eligibility (regular MC and QI-1) for MC recipients who have not met their share of cost.

25.17 QMB/SLMB/QI Income Determination and Budgeting Rules

These rules apply to QMB, SLMB and QI-1 recipients, including dual eligibles.

The following rules apply to QMB, SLMB and QI-1 income determinations:

• QMB, SLMB and QI-1 income eligibility is based on a percentage of the federal poverty level. The individual’s income must be less than the QMB, SLMB or QI-1 income limits.

Important:

The RSDI COLA (which is received in January) cannot be used to compute QMB, SLMB or QI-1 eligibility from January through March if it causes ineligibility. The Federal Poverty Level figures are published annually and are effective on April 1st. By disregarding the COLA increase, clients will not lose their Medicare benefits in the interim.



• Medi-Cal income rules are first used to determine QMB, SLMB, or QI-1) eligibility. If a couple is not eligible using Medi-Cal rules, a second budget is computed using SSI rules, as they may be more advantageous.

• SSI/SSP income is exempt for QMB.

• Do not count other public assistance income of the QMB/SLMB/QI applicant, spouse or child (e.g., SSI, or CalWORKs).

• Use the regular Medi-Cal income-in-kind rules, when applicable.

25.17.1 Budgeting, MC 176-1 QMB/SLMB/QI

CalWIN will compute the budget. In the event of a system outage, the budget can be manually determined as follows.

Determine the net non-exempt income of a QMB/SLMB/QI applicant or couple:

• Determine all members of the MFBU (eligible and ineligible). Include applicant, spouse, minor children (if any).

• Count gross unearned income.

• Allow the $20 any income disregard.

• Allow the $65 + 1/2 deduction from the gross earned income of the QMB applicant or spouse.

• The actual Impairment Related Work Expenses of a working, disabled QMB applicant/recipient are allowed as a deduction from his/her earned income.

• Do not deduct the health insurance premium and other allocations.

Table 25-7: MC 176-1

If the... Then...

QMB/SLMB/QI applicant is single or in his own MFBU If income is less than or equal to the QMB limit, he/she is QMB eligible.If income is less than the SLMB or QI-1 limits, he/she is SLMB for QI-1 eligible.

QMB/SLMB/QI applicant's spouse has no income The SSI income rules used on the MC 176 QMB/SLMB 2A will not help.

QMB/SLMB/QI applicant has a spouse with income or a spouse with income and minor children

Determine if there is QMB/SLMB/QI eligibility using SSI rules.



25.17.2 Budgeting, MC 176-2A QMB/SLMB/QI

The MC 176-2A QMB/SLMB/QI uses SSI income rules when a couple is over the QMB/SLMB/QI income limit when Medi-Cal rules (MC 176-1 QMB/SLMB/QI) are applied. Use this form only if the QMB/SLMB/QI applicant has an ineligible spouse, with or without children.

• Income can only be allocated to minor children from the gross unearned and earned income of the Ineligible Spouse.

• Complete Section II of the MC 176-2A QMB/SLMB/QI first if there are minor children in the home.

• Subtract the minor child's income from the Standard SSI Allocation. [Refer to Chart Book, “Maintenance Need (Effective 7/1/89),” page 5-8 for the Standard SSI Allocation, which changes annually.] (Compute separately for each child.)

Note:

Using SSI income rules, a minor child is defined as any child under age 18 or 18-21 and a student.

• Determine the income of the ineligible spouse (after allocating to the minor children).

• When the MC 176-2A QMB/SLMB/QI is used, only the QMB/SLMB/QI Income Limit for an individual or couple (one or two) is used.

Table 25-8: MC 176-2A

If the... Then...

Remaining gross income of the ineligible spouse is less than or equal to the Standard SSI Allocation, it is exempt.

Compare only the QMB/SLMB/QI applicant's income to the limit for one.If at or below the QMB limit for one, eligible.If below the SLMB/QI limit for one, eligible.

Remaining gross income of the ineligible spouse is greater than the Standard SSI Allocation

Combine the QMB/SLMB/QI applicant and spouse's income and use the QMB/SLMB/QI limit for two.

Refer to “Maintenance Need (Effective 7/1/89),” page 5-8 for the Standard SSI Allocation which changes annually.]

25.17.3 IRWE

The actual Impairment Related Work Expenses (IRWEs) of a QMB/SLMB/QI applicant/recipient which are necessary to become or remain employed can be deducted from his/her earned income only. Such expenses generally include:



• Those required to control a disabling condition thereby enabling the individual to work.

Examples: Prescriptions that are needed to control the disabling condition may be covered if they are not paid for by another source. However, routine prescriptions for unrelated medical conditions cannot be deducted from earnings.

• Those essential to perform the physical and/or mental demands of a job. (e.g., wheelchairs, prosthesis, etc.)

• Assistance in preparing for work and traveling to and from, (e.g., attendant care, transportation costs, exterior ramps or railings).

The actual cost to the QMB/SLMB/QI applicant must be verified.

Note:

Do not allow IRWE that are being paid (or will be paid) by another source (e.g., Medicare, Medi-Cal, the State Department of Rehabilitation, private insurance).

25.17.4 QMB/SLMB/QI Budgeting Sequence Chart

References to MC 176 forms only apply to manual budgets as CalWIN automatically computes and determines eligibility for these programs.

Table 25-9: QMBI/SLMB/QI Budgeting Sequence Chart

Family Composition Budget Sequence

Single QMB/SLMB/QI Applicant (no spouse or minor children)

Complete MC 176-1 QMB/SLMB/QI, Columns I and III.

• If the net-nonexempt income is less than or equal to the QMB limit, eligible.

• If the net-nonexempt income is less than the SLMB or QI-1 limit, eligible.

• If over, STOP. Not QMB/SLMB/QI eligible.



QMB/SLMB/QI Applicant with Ineligible Spouse (no minor children)


• If the net-nonexempt income is less than or equal to the QMB limit for 2, eligible.

• If the net-nonexempt income is less than the SLMB limit for 2, eligible.

If not eligible for QMB or SLMB using the MC 176-1 QMB/SLMB/QI, determine QMB/SLMB using the SSI rules. Complete the MC 176-2A QMB/SLMB/QI.

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, the ineligible spouse's income is exempt. Use the QMB/SLMB limit for one.

If not eligible for QMB or SLMB using the SSI rules, determine QI-1 eligibility.

• If the ineligible spouse’s income is NOT exempt, use the MC 176-1 QMB/SLMB/QI to determine QI-1 eligibility. Use the QI-1 limit for two.

• If the ineligible spouse’s income is exempt, use the MC 176-2A QMB/SLMB/QI to determine QI-1 eligibility. Use the QI-1 limit for one.

QMB/SLMB/QI Couple (both potentially QMB/SLMB/QI eligible, no minor children)


• If the net-nonexempt income is less than or equal to the QMB limit for two, eligible.

• If the net-nonexempt income is less than the SLMB or QI-1 limit for two, eligible.

• If over, STOP. Not QMB/SLMB/QI eligible.

QMB/SLMB/QI Couple (both potentially QMB/SLMB/QI eligible with minor children)

Complete MC 176-1 QMB/SLMB/QI using all 3 columns.

• If net-nonexempt income is less than or equal to the QMB income limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB or QI-1 income limit for the MFBU, STOP. Eligible.

If NOT eligible, consider the spouse with the most income as the ineligible spouse. Complete all sections of the MC 176-2A QMB/SLMB/QI (first Section II, then III, and Section I last).

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, after allocating to children, exempt it and use the QMB/SLMB/QI income limit for 1.

• If the ineligible spouse's income is more than the Standard SSI Allocation, count it and use the QMB/SLMB/QI income limit for 2. If over, STOP. Not QMB/SLMB/QI eligible.





25.18 Qualified Disabled Working Individuals (QDWI) Program

The Qualified Disabled Working Individuals (QDWI) Program requires the State to pay Medicare Part A premiums for disabled individuals who are under age 65 and who lost their Medicare benefits due to

Single Applicant with minor children and no spouse

Complete MC 176-1 QMB/SLMB/QI, all columns. STOP.

• If net-nonexempt income is less than or equal to the QMB limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB or QI-1 limit for the MFBU, STOP. Eligible.

QMB/SLMB/QI Applicant with ineligible spouse and minor children

Complete MC 176-1 QMB/SLMB/QI using all 3 columns.

• If net-nonexempt income is less than or equal to QMB income limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB income limit for the MFBU, STOP. Eligible.

If not eligible for QMB or SLMB using the MC 176-1 QMB/SLMB/QI, determine QMB/SLMB using SSI rules. Complete all sections of the MC 176-2A QMB/SLMB/QI (first Section II, then III, and Section I last).

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, after allocating to children, exempt it and use the QMB/SLMB income limit for one.

• If the ineligible spouse's income is more than the Standard SSI Allocation, after allocating to children, count it and use the QMB/SLMB income limit for two.

If not eligible for QMB or SLMB using the SSI rules, determine QI-1 using the MC 176-1 QMB/SLMB/QI and/or MC 176-2A QMB/SLMB/QI. If over, STOP. Not QMB/SLMB/QI eligible.

SSI/SSP Recipient Consider each SSI/SSP person to be in his/her own MFBU. Verify net nonexempt income using the Title XVI-SSI/SSP Information Screen [INQX] when available, or other verification. SSI/SSP is exempt.

• If countable income is less than or equal to QMB income limit for one, QMB eligible.

• If over the QMB income limit, ineligible.

Note:

SSI/SSP recipients are NOT eligible for SLMB/QI.





earned income in excess of the Substantial Gainful Activity (SGA) limit. QDWI does not pay any Medicare coinsurance, deductibles, or the Part B premium.

The State will notify counties of potential QDWI eligibles.

25.18.1 Effective Date

Eligibility begins the month of application if all eligibility requirements are met. Individuals may apply for 3-month retroactive QDWI if they were entitled to Medicare Part A in those months and are otherwise eligible.

25.18.2 Benefit

QDWI eligibles only receive state payment of their Medicare Part A premium. No Benefits Identification Card (BIC) is issued. QDWI eligibility can be viewed on MEDS, Aid Code 8A, on one of the Special Program screens.

25.18.3 Medicare Part A

QDWI applicants must enroll for the special 1818A Medicare program at Social Security. The initial enrollment period for this program is seven months from the date an individual receives notice from SSA that his/her Part A benefits under the regular Medicare program will end due to excess earnings. Individuals who do not enroll during this initial enrollment period must wait until the general enrollment period, January through March; their benefits will then start in July.

25.18.4 Eligibility Criteria

In order to qualify for QDWI, the applicant/recipient must not be otherwise eligible for any other MC program. That is, QDWI may not be approved for any individual who is active on MC without a SOC or whose SOC has been met. In addition, he/she must meet all of the following eligibility criteria:

Conditions

An individual must be eligible to enroll in Medicare Part A only under a special program (1818A) and meet all of the following conditions:

• Has not yet attained age 65

• Has been entitled to RSDI

• Continues to have the same disabling physical or mental condition

• Lost RSDI due to earnings in excess of the SGA limit.



• Is not otherwise entitled to Medicare.

Note:

In CalWIN, enter a Y value in the Eligible to Enroll in Medicare part A under 1818A field of the Collect Medicare Expense Detail window if the client meets the above conditions.

Other Requirements

QDWI applicants must meet all other Medi-Cal Program requirements.

Property Limit

The property limit is twice the Medi-Cal property limit, currently:

• $4,000 for one individual• $6,000 for two individuals

Citizen/ Non-citizen Status

QDWI eligibles must be a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits if applying for regular MC. An undocumented Non-citizen who would only get restricted MC benefits is not eligible for QDWI.

Income Limit

QDWI eligibles must have income at or below 200% of the Federal Poverty Level (FPL).

Important:

Unlike the QMB/SLMB and other FPL programs, the RSDI COLA received in January is not disregarded from January through March. The actual gross RSDI income is used to determine QDWI eligibility.

25.19 Medicare Part D Prescription Drug Program

MC no longer cover prescription drugs for individuals who are dually eligible (have both MC and Medicare) including SSI/SSP individuals and those who are in a MSP such as QMB, SLMB, and QI-1. Instead, the new Medicare Part D Prescription Drug Program will replace most MC prescription drug coverage to all persons who are eligible for Medicare Part A and/or Part B. Anyone who is eligible for Part A and/or Part B is eligible for Part D.



25.19.1 Part D Enrollment

Enrollment into Medicare Part D is mandatory for the following populations:

• Dually eligible individuals• MSP-only individuals, and• SSI/SSP individuals.

To facilitate this requirement, the Department of Health Services (DHCS) will automatically enroll all individuals listed above into a Prescription Drug Plan (PDP). Individuals can also enroll themselves directly into the PDP of their choice.

25.19.2 Prescription Drug Plan (PDP)

Medicare beneficiaries who choose not to enroll when they first become eligible may have to pay a higher premium if they later decide to enroll in a plan. They will also need to wait until the annual general enrollment period (October 15 through December 7 of each year) to sign up for a plan. Each plan has its own distinct list of covered drugs called a formulary. For this reason, it is important that Medicare beneficiaries select their PDP to ensure that their current prescriptions are covered. Each plan can design their benefit package and has the flexibility to offer supplemental benefits for a higher premium.

Full-scope dual eligible and MSP individuals who do not select a plan will be automatically enrolled into a Prescription Drug Plan (PDP).

• Individuals with Medicare HMOs (e.g. Kaiser Senior Advantage, Secure Horizons, Health Net, etc.) will receive their prescription coverage through their respective plans.

• Individuals with traditional fee-for-service Medicare will be randomly assigned to a Prescription Drug Plan (PDP) if a plan is not selected.

The PDP will notify them by mail once they are enrolled. Dual eligibles and MSPs may change plans at any time after the auto-enrollment if they are dissatisfied with the plan assigned to them.

25.19.3 Enrollment in a Plan

Self-enrollment is encouraged to ensure that selected PDP covers their current prescription drugs. Medicare beneficiaries (or their authorized representatives) can enroll themselves directly in a plan. Plans are required to process applications in a timely manner and the plan must notify the applicant of the acceptance or denial of the enrollment request.



Medicare Recipients with Other Health Coverage (OHC)

Individuals who have OHC (through employers, retirement plans or unions) that covers prescription drugs can decide whether to continue their existing drug coverage or enroll in a Medicare PDP. Covered individuals can also contact their OHC carriers to get the needed drug comparison. As long as the current OHC plan is at least as good as what is offered by Medicare PDP, he or she will not be subject to the penalty of a higher premium if s/he decides to join the Medicare PDP later. Otherwise, they need to enroll in a Medicare PDP when first eligible to avoid paying a higher premium later on (after the initial enrollment period).

Medicare Recipients who Have Medigap Policies

Medigap policies cover some of the costs that are not covered by Medicare. In most states (except for Minnesota, Massachusetts and Wisconsin), the standardized policies are called Medigap Plans A through J. Some of these Medigap Plans (Plan H, I and J) have drug benefits.

Table 25-10: Medicare Recipients who Have Medigap Policies

If the Medigap Plan... Then...

Does not provide drug benefits, The Medicare drug coverage will not change.

Provides drug benefits, The Medicare recipient can either keep the current Medigap drug benefit or enroll in a Medicare PDP to get drug coverage. He or she can keep the Medigap supplemental coverage.

25.19.4 Costs

The new Part D has a premium of around $37, annual deductible of $250 and copays/coinsurances. The costs will vary depending on which drug plan they choose and some plans may offer more coverage and additional drugs for a higher monthly premium. Unlike Part A or B, there is no buy-in program for Part D premium. The client must be allowed an income deduction if he/she is paying out-of-pocket Part D premium, deductibles, copays/coinsurances.

Table 25-11: Costs

Costs/Descriptions Beneficiaries’ Out of Pocket Expenses

Monthly Premium Averages $37/mo.

Annual Deductible up to $250

If the initial prescription cost is ($250-$2,250) 25% of the cost up to $500

If the prescription cost is ($2,250-$5,100) 100% coinsurance not to exceed $2,850

If the prescription cost is greater than $5,100 Greater of 5%, OR$2 after $3,600 spent above



25.19.5 Low Income Subsidy (LIS) Assistance

The LIS provides assistance for the costs of premiums, deductibles and copays. Persons with limited income (below 150% FPL) and resources (single - less than $14,390; married - less than $28,720) can get help in paying the costs by applying for the LIS assistance.

Dually eligible full -scope MC eligibles (have both Medicare and MC including those on SSI/SSP) and those who are MSP eligibles do not need to apply for the subsidy as they automatically qualify and will be approved for LIS assistance. Once approved for LIS, they do not have to pay premiums or deductibles and will have low copays between $1-$5 for prescriptions up to $5,100. There is no copay for prescriptions over $5,100. For institutionalized (in LTC) individuals, there is no copay at all.

Individuals who do not automatically qualify for LIS must apply.

Table 25-12:

BenefitIncome At or Below 100% FPL

Income over 100% FPL

Income Below 135% FPL and with Limited Resources

Income Over 135% FPL with Higher Resources

Income Below 150% FPL with Higher Resources

Monthly Premium

$0 $0 $0 $0 Sliding Scale

Annual Deductible

$0 $0 $0 $50 $50

Initial Prescription Benefit($0-$5,100)

$1/$3 copays $2/$5 copays $2/$5 copays Maximum 15% coinsurance

Maximum 15% coinsurance

Institutionalized/LTC (excluding waiver programs) individuals pay $0.

100% Coinsurance

N/A N/A N/A N/A N/A

Catastrophic Benefit Period (prescriptions greater than $5,100)

$0 $0 $0 $2/$5 $2/$5

LIS and MC Share-of-Cost (SOC) Calculation

Dually eligible recipients with a SOC are eligible for LIS beginning in the first month they meet their SOC. Once approved, LIS eligibility continues through the end of the calendar year. It is not contingent on maintaining eligibility and is not subject to change if there are changes in their income or asset levels.



25.19.6 Information/Referral Resources

To ensure that clients are referred to the appropriate agency, the following chart is provided:

Table 25-13: Information/Referral Resources

NAME Area of Expertise Phone Number/ Website

Center for Medicaid Services (CMS)

Part D enrollment/questions

(800) MEDICARE www.medicare.gov

Social Security Administration LIS Applications (800) 772-1213 or local Social Security officewww.ssa.gov

Health Insurance and Client Advocacy Program (HICAP)

Help/guidance on PDP selection

(800) 434-0222

25.19.7 Implementation

Intake offices must ensure availability of pre-assembled packets in their respective lobbies to be handed out or sent by mail to those who want an LIS application. Each packet must include the following:

• LIS Cover Page• A MC mail-in application• QMB/SLMB/QI-1 application, and• LIS application.

All Offices

If an individual completes and provides an LIS application (in person or by mail) regardless whether or not the individual submits a MC or MSP application, all completed LIS applications must be forwarded to SSA by batch using the self-addressed envelope included with each LIS application. Each District Office must determine a process for designating a basket for batch purposes. A photocopy of an LIS application is not acceptable. Only original LIS application form must be used. If an individual insists upon an LIS eligibility determination by the State or refuses to have his/her LIS application forwarded to SSA, it must be forwarded in batch to:

DHCS/MEBAttn. MMA Analyst1501 Capitol Avenue, MS 4607Post Office Box 997417Sacramento, CA 95899-7417



25.19.8 Santa Clara Family Health Plan (SCFHP) Medicare Plan

SCFHP offers a Medicare Advantage plan called Healthy Generations (HG). It is for people who:

• Live in Santa Clara County,• Are dually eligibles (have both MC and Medicare Part A and Part B).

For additional information, clients can call 1-888-355-5557. For hearing or speech impaired: TTY 1-800-735-2929.

25.20 Low Income Subsidy Applications

The Social Security Administration (SSA) is required to refer Medicare Part D Low Income Subsidy (LIS, also known as Extra Help) applicants to the state for Medicare Savings Programs (MSP) determinations with their consent. In addition to MSP, the State of California elected to also determine eligibility for full MC benefits. LIS applicants who require evaluation for MSP and/or MC eligibility are referred to the counties via MEDS daily worker alerts.

25.20.1 Application Date

The date of application for MC and MSP is the date the applicant filed for LIS Extra Help. This date is displayed on the [LIS1] screen in the APPLICATION-DATE field.

If there is already an existing MC/MSP application (pending or active), the application date that would be most beneficial to the applicant must be used.

If the applicant has applied for LIS more than once, all LIS application dates will appear on the [LIS6] screen. Each date is associated with the information received from SSA for that application. Information included in each application (income, resources, etc) must be used to help evaluate MC and/or MSP eligibility. The application date(s) not used for MC/MSP determination must be denied, either as duplicate application or for not meeting eligibility requirements.

Reminder:

The QMB effective date has not changed. QMB eligibility begins the first day of the month following the month in which QMB is authorized in CalWIN.



25.20.2 Processing Timeframe

Determination of MC/MSP eligibility must be completed within 45 days from the date the county receives the LIS alert. This date is normally one business day following the COUNTY-REFERRAL-DATE shown on the [LIS1] screen.

25.20.3 Retroactive Benefits

LIS applicants can also apply for retroactive MC, SLMB and/or QI-1 benefits from the date of the LIS application. To request retroactive coverage, applicants must have medical expenses for the month(s) requested.

Note:

The “Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210 A) must be completed as applicable.

25.20.4 Alerts

The following daily alerts are generated for LIS applicants:

• 9057 MIPPA LIS App - Current MSP Elig but Not Current Medi-Cal Elig

• 9058 MIPPA LIS App - Current Medi-Cal Elig but Not Current MSP Elig

• 9059 MIPPA LIS App - Current Medi-Cal and MSP Eligible

• 9055 MIPPA LIS App - No Matching Record Found on MEDS

• 9056 MIPPA LIS App - Not Current Medi-Cal or MSP Eligible

Alert 9057 through 9059

For Alerts 9057-9059, refer to User’s Guide, Chapter 11, “9057 - MIPPA LIS APP - Current MSP Elig but Not Current Medi-cal Elig - Urgent,” page 10-38 for instructions.

Alert 9055 and 9056

For Alert 9055 and 9056, follow the steps below:



Table 69: Process for Alert 9055 and 9056

Step Who Action

3. Designated Clerical Staff at MBA

• Prints the “LIS Applications” report daily.• Completes file clearance procedures in CalWIN and MEDS.

For individuals that already have an active or pending case:

• Notifies assigned EW or unit via email or TMT. On the subject/note line, enters “Urgent - LIS Alert 9055/9056”.

For individuals who do not have an active or pending case:

• If the client does not return the packet, note that the client did not return the packet on the LIS Spreadsheet. Send the MC 239 A LIS DENIAL for failure to comply or whereabouts unknown, as appropriate.

25.20.5 Denial

A denial letter must be sent in the following situations:

• LIS application date provides no benefit in terms of the beginning date of MC/MSP eligibility (for clients already active on MC/MSP)

• The applicant does not return the packet or attempt to make contact,• Failure to provide verification.

• Sends the MC packet and CalFresh letter with the SCD 2269 coverletter which explains the client’s right to opt out of an MC and/or MSP evaluation.

• Completes the Application Registration process.

• Use the APPLICATION-DATE shown on the [LIS1] screen.

• Select “Low Income Subsidy” from the Application Source drop down field.

• Assign the application to MBA caseload #DMZA

Table 70: LIS Notice of Action Usage

Notice of Action Availability Use

MC 239 A - LIS DENIAL DEBS Forms If an LIS applicant is already active on MC and/or MSP in CalWIN, the LIS denial must be manually printed from DEBS Forms.

MC 239 A CalWIN If the LIS applicant is determined ineligible for MC, the MC 239 A must be sent.



25.20.6 Documentation

The result of MC and/or MSP eligibility determination must be clearly documented in the Maintain Case Comments window and the LIS spreadsheet, including the reason of the denial if the LIS application is denied.

MC 239 K CalWIN If the LIS applicant is determined to be ineligible for MSPs, use the MC 239 K. Note: If the applicant is also ineligible to MC, an MC 239 A must also be sent.

Table 70: LIS Notice of Action Usage

Notice of Action Availability Use


