County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Introduction to Medicare Savings Programs MSP Number Page 5131 1 of 1 Revision Date January 1 2020 Background This program was mandated by the Medicare Catastrophic Coverage Act of 1988 and was implemented in California on January 1 1990 The Medicare Savings Programs MSP are the Qualified Medicare Beneficiary QMB Specified LowIncome Medicare Beneficiary SLMB Qualifying Individual QI and Qualified Disabled and Working Individual QDWI programs The benefits of each are explained in the associated sections Purpose This article provides regulations and instructions for the MSP This article has been rewritten in the new format and instructions updated Policy The following sections contain the regulations for the MSP and instructions for evaluating for these programs Procedure Follow the instructions in the following sections to evaluate for these programs Program Impacts None References ACWDLs 8990 and 0055 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Benefit Explanation Number Page 5132 1 of 2 Revision Date January 1 2020 Background This section provides an explanation of the benefits received by Medicare beneficiaries and the Medicare application requirements Purpose This section has been rewritten in the new format Policy A Scope of Benefits Medicare Part A hospital insurance includes inpatient hospital care medically necessary not custodial inpatient care in a skilled nursing facility home health care and hospice care Medicare Part B medical insurance includes doctors services outpatient hospital care diagnostic tests durable medical equipment ambulance service and many other health services and supplies B Deductibles and Coinsurance Both Part A and Part B have deductibles and coinsurance A deductible must be paid in advance before Medicare will make any payments Coinsurance is a 20 charge to the beneficiary for the service C Medicare Part A Enrollment 1 Costs Most Medicare beneficiaries receive Part A insurance at no cost no premium However those who have not qualified for free Part A benefits solely because they lack the required amount of Social Security Administration SSA covered employment may purchase Part A with a premium MediCal will pay this monthly Part A premium for QMBs who are not qualified for free Part A benefits 2 Enrollment Period If an individual is not already receiving Part A application A can only be made at one of the following times 1 During the initial enrollment period which is no earlier than 3 months before age 65 but no later than 3 months after the individuals 65th birthday 2 After 24 months of receiving Title II disability benefits to be effective in the 25th month 3 The month after a person stops working if heshe is over 65 4 When receiving dialysis related health care services 5 During the general enrollment period of JanuaryMarch to be effective the following July for those Medicare beneficiaries who do not enroll when they are initially eligible as indicated in 1 through 4 above 3 Penalties An individual who does not apply for Part A at the first opportunity is charged a penalty by the SSA Under the QMB program the state will pay the penalty for a Medicare beneficiarys late enrollment in Part A County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Benefit Explanation Number Page 5132 2 of 2 D Medicare Part B Enrollment 1 Costs Part B can only be received if purchased In addition there is a Part B annual deductible and coinsurance charge since Medicare will only pay 80 of the approved Medicare rate 2 Enrollment Period Those not on MediCal BuyIn for Part B have the same enrollment period as for Part A For QMBonly and those already on MediCal BuyIn the initial and general periods of enrollment are waived and eligibility will begin at the time of approval 3 Penalties There is a penalty for late enrollment in Part B like that of late enrollment for Part A however under the BuyIn agreement the state is not charged a penalty for those Medicare beneficiaries who enroll late in Part B Procedure See the following sections for evaluation of each MSP Program Impacts None References ACWDL 9146 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 1 of 6 Revision Date January 1 2020 Background The Qualified Medicare Beneficiary QMB Program is one of the Medicare Savings Programs MSP It benefits QMB recipients who will have their Medicare premiums deductibles and coinsurance fees paid for by MediCal Recipients will also receive some drug cost sharing benefits Eligibility requirements are listed in this section Purpose This section provides information about the QMB program This section is rewritten in the new format Policy There are two groups of QMBs Those who receive regular fullscope MediCal either as cash grant recipients such as SSI or CalWORKs or NonMAGI MediCal beneficiaries who therefore meet the MediCal property limits and who are determined to meet the QMB income requirement This group is dually eligible eligible for nonMAGI MediCal and QMB benefits Those eligible as a QMBonly who do not want nonMAGI MediCal or who are not eligible for nonMAGI MediCal due to having property above the nonMAGI MediCal property limit A Federal Financial Participation FFP FFP will be paid for individuals who are eligible for the QMB Program Thus it is to the states advantage to enroll individuals with Part A at no cost in QMB if eligible MediCal applications and redeterminations must be reviewed for QMB eligibility If no QMB eligibility exists complete a review for SLMB andor QI B Benefits to QMB Eligible Individuals 1 QMBOnly Most QMBonly applicants receive Part A at no cost and will be applying for MediCal to pay their Part B premiums and their Part A and Part B coinsurance and deductibles Thus the QMB benefit for them is an increase in monthly spendable income Those who pay for Part A estimated to be a small number will experience an even larger increase in spendable income Those who are eligible as a QMBonly will be reported to MEDS as aid code 80 Their MediCal eligibility will indicate that they are limited to Medicare deductibles and coinsurance benefits 2 DualEligible Individuals Dual eligible individuals are those who receive regular MediCal benefits including CalWORKs recipients and are also eligible for QMB Individuals who are receiving regular MediCal and who also receive Part A at no cost will have no additional income benefits by receiving QMB because MediCal already pays their Part B premiums as well as their Part A and B coinsurance and deductibles BuyIn As current MedicareMediCal crossovers they already may have access to a wider choice of providers since they are not limited to a MediCal contact hospital they can go to a noncontract MediCal hospital Current MediCal beneficiaries who pay a monthly Part A premium County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 2 of 6 will benefit in increased spendable income from MediCal paying their Part A premiums The state will benefit by receiving FFP for these QMB recipients Those MediCal beneficiaries who do not now have Part A but who will now enroll in Part A as a QMB may have a wider choice of providers since they would not be limited to a MediCal contract hospital but could use a hospital that accepts Medicare For dual eligible cases when there is an existing County case CalWIN will report QMB eligibility in the case Those with dual eligibility will be reported to MEDS as aid code 80 in addition to their current aid code They will show their current aid code on MEDS with aid code 80 in one of the special program segments They will receive MediCal cards with the message or absence of a message normal for their regular aid code and recipient status C Application Processing 1 NonSSI Applicants A simplified mailin statement of facts the MC 14 A is used for the QMB Program However an applicant who completes a Single Streamlined Application or SAWS 2 PLUS to apply for MediCal does not have to complete an MC 14 A if it is determined that such an individual should be evaluated for the QMB Program Answers on the application may be clarified by telephone The SAWS 1 and MC 219 are not required However the MC 219 must be provided to the applicant Copies of all required verifications including income and property are acceptable The MC 13 is required at application for noncitizens whose status is not everified For citizensnationals the citizenshipnational status declaration may be made on the Statement of Facts or a sworn statement which contains a declaration of citizennations status and place of birth The MC 14 A does not meet this requirement since there are no citizenship questions 2 SSI Applicants SSI recipients applying for QMB are not required to complete an MC 14A A facetoface interview is not required D Eligibility Criteria 1 Property QMB property limits are higher than the nonMAGI MediCal property limit See MPG 111 Appendix A for the current limit Use Form MC 176PA and PC QMBSLMBQI for property evaluations a Property Limit Met If the QMB applicant is receiving MediCal from another program for example nonMAGI MediCal SSI CalWORKs the QMB property requirement is met If one or both members of a married couple living together are applying for QMB benefits but only one member is receiving MediCal from another program the QMB property requirement is met for both members b Two Methods for DualEligible Individuals If the QMB applicant is not receiving but is also applying for regular MediCal at the same time as the QMB application there are two methods for determining if the QMB property requirement is met County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 3 of 6 METHOD I This method is the regular method of determining MediCal eligibility and follows the normal MediCal rules found in Article 9 IF INELIGIBILITY RESULTS FROM METHOD I THEN EVALUATE ELIGIBILITY UNDER METHOD II TO DETERMINE IF QMB PROPERTY ELIGIBILITY CAN BE ESTABLISHED METHOD II This method is used for QMB only applicants and dual applicants whose property exceeds the normal MediCal property limit Step Action 1 Only consider the property of the QMB applicant and spouse if any Do not consider the property of any other family members in the home 2 Determine the net nonexempt property in accordance with Article 9 3 Compare the net nonexempt property to the MSP property limit for one person or the MSP property limit for two people if the spouse is at home regardless of whether the spouse is a QMB applicantbeneficiary See MPG 111 Appendix A If the result Then the Is equal to or less than the MSP property limit QMB property limit is met Exceeds the MSP property limit Applicant is ineligible for QMB due to excess property Note A QMB applicant who is between 18 and 21 years of age is considered an adult under Method II even though heshe would be treated as a child in determining eligibility for regular MediCal for example is a blind or disabled person who is 18 to 21 years of age living in the home of a parent and currently in school Therefore the applicants property is combined with the parents property for the MediCal eligibility evaluation Method I but is counted separately if Method II is used c QMBOnly If the QMB applicant is applying as a QMBonly use Method II to determine eligibility d QMBChildren A QMB child has special methodology for property evaluations The only people who are eligible as QMB children are dialysis patients under 18 years of age Use Method II Consider only the property of the child and the parents andor stepparent in the home Do not consider the property of any other family members Subtract the property limit for the number of parents in the home from the net nonexempt property The net result is the amount of property allocated to the QMB child applicant Add this amount to the childs own net nonexempt property Compare the result to the QMB property limit 2 Income Limit Net nonexempt income must not exceed 100 of the federal poverty level See MPG 111 Appendix A for current poverty level figures County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 4 of 6 a Budget Process for NonSSI Recipients MediCal Use MediCal income methodology except for Deductions for health insurance and Medicare premiums are not allowed Deductions for Impairment Related Work Expenses IRWE are allowed See MPG 1063N for details Use actual income do not apportion b Budget Process for NonSSI Recipients SSI Income Methodology use only for NonSSI Recipients with family members If ineligibility results after using MediCal methodology determine the net nonexempt income following SSI income methodology Because SSI income methodology allows for deductions not allowed under MediCal there may be family circumstances where SSI income methodology is less restrictive than MediCal income methodology SSI income methodology allows the ineligible spouse of a QMB applicant to reduce hisher gross nonexempt income by 1 Allocating income to ineligible minor children residing with the applicant less income the children may have This is known as the Standard QMB Allocation For QMB determinations minor children are defined as eighteen years of age or younger 2 If the remaining income of the ineligible spouse is less than the Standard QMB Allocation amount consider the income exempt Use Form MC 1761 QMBSLMBQI and MC 1762A or B QMBSLMBQI for budgeting c Budget Process for SSISSP Recipients Since QMB and SSI eligibility are the same except for income and Medicare Part A enrollment only verify these two eligibility factors Income will be verified by the MEDS SDX screen If SSI income which is exempt is at least the difference between SSI payment level and the current QMB percentage of federal poverty level then the SSISSP recipient is income eligible Do not determine the net income of SSI recipients Accept the income determination of SSA For applications of an SSI couple each individual will be evaluated separately for income eligibility The net income as determined by SSI will be compared to the QMB limit for one person Separate MFBUs will be established for each SSI individual Note SSIQMB cases are not subject to IEVS 3 Eligibility for Part A with or without a premium Verification of Part A is required IEVS or MEDS can be used as verification 4 Be otherwise eligible for MediCal they must meet all other MediCal requirements such as California residency and linkage for example aged blind disabled County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 5 of 6 E Beginning Date of Aid For Part A recipients the effective date of eligibility for QMB benefits is the first day of the month following the date on which the County makes the determination of eligibility For those applicants who are required to enroll in Part A during the general enrollment period of January through March July is the effective date of eligibility for QMB benefits There is no retroactive QMB eligibility F Redetermination For dual eligible individuals make the redetermination of QMB eligibility concurrently with the MediCal redetermination For QMB only the period of eligibility will be one year Use Form MC 14 A for the mailin redetermination Copies of income and property verifications are acceptable During QMB redeterminations for SSI recipients verify the beneficiarys income and Part A eligibility by viewing MEDS screens The verified information will then be narrated in the case file G Reinstating Eligibility Due to Administrative Error When a QMB case is erroneously discontinued at no fault of the beneficiary the error is an administrative error and must be corrected Reinstate eligibility for past months when a beneficiary was eligible and should have been covered 1 For MediCal to retroactively pay for all premiums in arears reinstate QMB eligibility on the MEDS Special Program Screen using Aid Code 80 effective the date that the QMB eligibility was erroneously discontinued 2 Once the continuous QMB eligibility reporting has been entered into MEDS the States Medicare BuyIn system will process a Part A BuyIn transaction This transaction will generate Part A and B coverage and pay SSA for all past premiums 3 If the Part A BuyIn transaction does not process correctly submit a Medicare BuyIn Problem Report online to the Department of Health Care Services Medicare BuyIn Unit CalWIN and MEDS must reflect the same correct information Failure to do so will result in reconciliation problems Add the QMB program if it is not properly reflected in CalWIN with the effective begin date of the month of erroneous discontinuance either When first in Application Registration In Collect Individual PriorCurrent Aid Detail window H Card Issuance See MPG 142 Procedure Follow the procedures above to evaluate for the QMB Program Program Impacts None County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Medicare Beneficiaries QMB Number Page 5133 6 of 6 References ACWDLs 9943 9961 0314 and 0524 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Specified LowIncome Medicare Beneficiaries SLMB Number Page 5134 1 of 2 Revision Date January 1 2020 Background The SLMB Program one of the Medicare Savings Programs began January 1 1993 A SLMB must be entitled to Medicare Part A have no more than the MSP property limit have income at or below 120 percent of the federal poverty level FPL and be a citizen or alien who would be eligible for full benefits if heshe were eligible for a regular MediCal program The SLMB Program does not pay the Part A premium or the Part B deductible or copayment Purpose This section is rewritten to the new format and procedures updated Policy A Scope of Benefits SLMB pays the Part B premium only B Enrollment Enrollment may take place at any time The beneficiary need not enroll during the Initial Enrollment Period or the General Enrollment Period C Application A facetoface interview is not required to apply for the SLMB program The statement of facts for the SLMB program is the simplified mailin form MC 14 A However the Single Streamlined Application may also be used For a SLMB only application an applicant who completes the MC 14 A does not have to complete the Single Streamlined Application Likewise an applicant who completes the Single Streamlined Application does not have to complete the MC 14 A The SAWS 1 and MC 219 are not required However the MC 219 must be provided to the applicant An MC 13 is required at application for noncitizens whose status is not everified For citizensnationals the citizenshipnational status declaration can be made on the Statement of Facts or a sworn statement which contains the statement of citizennational status and place of birth The MC 14 A does not meet this requirement as there are no citizenship questions The day the FRC receives the SLMB application the Intake scheduling person is to assign the Intake to a worker A mailin SLMB application is to be treated the same as a facetoface appointment for the purpose of scheduling Intakes and assigning to workers Register the application in the assigned workers number the day the SLMB application is received by the FRC Review MediCal applications and redeterminations for SLMB eligibility The SLMB applicant beneficiary must be determined ineligible to QMB before SLMB eligibility may be established If no SLMB eligibility exists complete a review for QI eligibility D Retroactive Benefits Unlike QMBs SLMBs may have up to three months of retroactive benefits immediately preceding the month of application County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Specified LowIncome Medicare Beneficiaries SLMB Number Page 5134 2 of 2 E Aid Codes Aid Code 8C is used for SLMB eligibility F MediCal Cards The SLMB Program will not have MediCal cards issued as beneficiaries will not receive any MediCal services other than payment of the Part B premium G Redetermination For dual eligible individuals make a redetermination of SLMB eligibility concurrently with the MediCal redetermination For SLMB only beneficiaries the period of eligibility will be one year Form MC 14 A will be used for the mailin redetermination Copies of income and property verifications are acceptable Procedure Follow the steps above to evaluate for the SLMB Program Program Impacts None References ACWDLs 9261 9943 9961 0055 and 0314 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualifying Individual QI Number Page 5135 1 of 3 Revision Date January 1 2020 Background The Qualifying Individual QI program is another of the Medicare Savings Programs MSP It pays the full Medicare Part B premium Purpose This section has been rewritten into the new format and procedures updated Policy A Application A simplified mailin statement of facts the MC 14 A is used for the QI Program However an applicant who completes a Single Streamlined Application does not have to complete an MC 14 A if it is determined that such an individual should be evaluated for the QI Program Nor does an applicant for the QI Program have to complete a Single Streamlined Application to apply for MediCal if not found eligible to QI Either form is acceptable as an application for the QI Program The SAWS 1 and MC 219 are not required However the MC 219 must be provided to the applicant The application date is the earlier date of the following the date the MC 14 A is stamped received by the county the SAWS 1 date or the date the applicant called the county about the QI Program if known The day the FRC receives the QI application the Intake scheduling person is to assign the Intake to a worker A mailin QI application is to be treated the same as a facetoface appointment for the purpose of scheduling intakes and assigning to workers Register the application in the assigned workers number the day the QI application is received by the FRC A facetoface interview is not required to apply for the QI Program Answers on the application may be clarified by telephone Copies of all required verifications including income and property when a discrepancy exists are acceptable An MC 13 is required at application for noncitizens whose status is not everified For citizensnationals the citizenshipnational status declaration can be made on the Statement of Facts or a sworn statement which contains a statement of citizennational status and place of birth B Eligibility Requirements The eligibility requirements and methodologies are the same as for the QMBSLMB Program only the income standards are different The person who applies for the QI Program must first be determined ineligible for the QMB or SLMB Programs before being evaluated for the QI Program Those aliens eligible for emergency and pregnancy related services only are not eligible for QI Program C Income Standards If the otherwise eligible individuals net nonexempt income is at or above 120 percent of the Federal Poverty Level FPL but less than 135 percent of the FPL the individual is eligible under the QI Program see MPG 111 Appendix A for current poverty level figures Use form MC 1761 QMBSLMBQI1 and MC 176 QMBSLMBQI1 2A or 2B for calculating the QI budget As with the QMBSLMB Programs the SSA COLAs that occur in January of each year are to County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualifying Individual QI Number Page 5135 2 of 3 be ignored and the increases not counted as income until the new FPLs come into effect April 1 of each year Also as with QMBSLMB Programs health insurance premium payments paid by the applicantbeneficiary are not an income deduction D Property Limits The property limits are the same as the QMBSLMB Programs To determine property eligibility use Form MC 176 PA QMBSLMBQI for adults or MC 176 PC QMBSLMBQI for children Do not request verification of property from QI applicantsbeneficiaries unless an unresolved discrepancy exists Request an IEVS report at application and redetermination Also review property reported on a previous MediCal statement of facts If an unresolved discrepancy exists between reported property and property reflected on IEVS or a previous statement of facts request verification of property Use an IEVS contact letter when requesting property verification due to an IEVS discrepancy see MPG 486 E EligibilityIneligibility When an ApplicantBeneficiary Is Eligible for MediCal WithWithout a SOC Federal law precludes QI eligibility when there is concurrent eligibility under a different MediCal Program without a SOC or the SOC has been met If there is eligibility under a nonQI MediCal Program A QI applicant eligible to share of cost MediCal may be eligible to QI if all other QI eligibility factors are met A QI applicantbeneficiary eligible to zero share of cost MediCal must be denieddiscontinued Review MediCal applications and redeterminations for QI eligibility Determine if the QI applicant beneficiary is ineligible to QMBSLMB before QI eligibility may be established F Benefits The QI Program pays the Medicare Part B premiums for eligible individuals G Aid Codes Aid Code 8D is used for QI H Retroactive Benefits Like the SLMB Program QI individuals are eligible for three months of retroactive benefits When determining retroactive benefits the federal poverty level FPL limits in effect for that time period must be used The FPL charts are included in MPG 111 Appendix A I Redetermination The period of eligibility for QI beneficiaries is one year Complete an annual redetermination concurrently with the MediCal case if the beneficiary is a QI recipient eligible to Share of Cost MediCal QI only beneficiaries use mailin form MC 14 A to complete the redetermination process County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualifying Individual QI Number Page 5135 3 of 3 Procedure Follow the regulations above to evaluate for the QI Program Program Impacts None References ACWDLs 9943 9961 and 0314 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Disabled and Working Individual QWDI Number Page 5136 1 of 2 Revision Date January 1 2020 Background The Omnibus Budget Reconciliation Act of 1989 required that the State pay for Medicare Part A premiums for individuals who lost Title II and Medicare benefits due to earned income above the required Substantial Gainful Activity SGA limit Unlike the QMB Program MediCal is not required to pay coinsurance and deductibles or the Part B premium Purpose This section is rewritten in the new format and procedures updated Policy A Eligibility Requirements A potentially eligible QDWI individual 1 Is entitled to enroll in Part A for the disabled and working special program 1818A and who meets all the following Has not attained age 65 Has been entitled to disability insurance benefits under Title II Continues to have a disabling physical or mental condition Lost Title II benefits due to earnings exceeding the SGA limits Is not otherwise entitled to Medicare 2 Has net nonexempt income at or below 200 of the federal poverty level Determine net nonexempt income following SSI methodology Use Form MC 176 QDWI to determine the income eligibility for QDWI 3 Has nonexempt property at or below the MSP property limit Only consider the property of the QDWI and if married hisher spouse if living in the same home in determining net nonexempt property Use Form MC 176 QDWI2 to determine the property eligibility for QDWI 4 Must meet all other nonfinancial requirements that a full MediCal beneficiary meets such as cooperation state residency citizenship etc Individuals ineligible to QWDI 1 An individual eligible for MediCal benefits is not eligible for the QDWI Program 2 An individual who does not meet the eligibility requirements for fullscope MediCal benefits is not eligible to QDWI This includes aliens who are eligible to receive only restricted MediCal benefits B Aid Code Aid Code 29 is used for QDWI C Retroactive Benefits Retroactive QDWI benefits for three months before the month of application is permitted if the individual is entitled to Part A benefits in those retroactive months and is otherwise eligible County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Qualified Disabled and Working Individual QWDI Number Page 5136 2 of 2 D Social Security Administration SSA Determination SSA notifies individuals on an ongoing basis when they become potentially eligible for this program SSA will determine if an individual meets the eligibility requirements above before referring the individual to apply at the FRC E Benefits Provided Under the QDWI Program MediCal will pay the Part A premium for individuals qualified under this program No MediCal Benefit Identification Card BIC will be issued simply because of an individual being eligible for this program The individual will continue to use hisher Medicare card F Period of Eligibility Period of eligibility for this program shall be in accordance with MPG 131 Procedure Follow the requirements above to evaluate for the QDWI Program Program Impacts None References MEPM 5I2 ACWDLs 9048 and 90101 Sunset Date This policy will be reviewed for continuance by December 31 2022 Approval for Release Rick Wanne Director Eligibility Operations