County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Number Page 1504 1 of 4 Revision Date 812021 BackgroundMedicare is a federally administered health insurance program for qualified individuals Medicare benefits are divided into three parts 1 Part A Hospital Insurance 2 Part B Supplementary Medical Insurance 3 Part D Prescription Drug Coverage Purpose This section provides staff with information about Medicare and Medicare BuyIn the process in which the Department of Health Care Services DHCS pays Medicare Part B premiums for some qualified MediCal beneficiaries The section has been reformatted and information on BuyIn problems was updated to reflect the current online process Policy A Medicare EligibilityRequirement for MediCal Beneficiaries to Apply for Medicare As a condition of MediCal eligibility customers must apply for Medicare if they qualify If a customer is eligible prior to turning age 65 inform the customer they must apply for Medicare If a customer is over 65 and it is past their initial enrollment period generally the three months after their 65th birthday inform the customer they must apply during the next Medicare open enrollment period which occurs annually from January 1 through March 31 Do not delay granting MediCal awaiting verification that the customer applied for Medicare if the customer is otherwise eligible Eligibility for Part A Part B and Part D The following customers are eligible to Part A Part B and Part D Medicare benefits Customers or their spouses eligible to Railroad Retirement RRSocial Security Administration SSA based Medicare with the required quarters of employment Customers who are 65 years of age or over Customers who are disabled or blind for at least 24 consecutive months under SSA Title II Customers with chronic renal disease meeting requirements for the receipt of Medicare Eligibility for Part B Only Customers who are eligible to Medicare Part B only include Those who are not eligible to Part A Those who are 65 years of age or older United States US citizens or noncitizens legally present in the US for at least five years B Medicare Part B Benefits Coverage After the customer pays the required deductible amount Medicare Part B pays 80 percent of charges for most noninstitutional medical services such as physician services home health agency services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Number Page 1504 2 of 4 and drugs which cannot be selfadministered Zero share of cost SOC MediCal may pay both the deductible and charges over 80 percent for Medicare beneficiaries Payment of Premiums Part B is a voluntary health insurance program that is financed by premiums from qualified enrollees and supplementary federal funds DHCS pays these premiums for eligible MediCal and Supplemental Security IncomeState Supplemental Program SSISSP customers with zero SOC or those who have met their monthly SOC Customers eligible for Medicare Savings Programs MSP Qualified Medicare Beneficiary QMB Specified LowIncome Medicare Beneficiaries SLMB and Qualifying Individual QI are eligible for payment of Part B premiums regardless of whether they are eligible for MediCal under another program with or without a SOC C Medicare Part B BuyIn BuyIn Eligibility BuyIn refers to the arrangement through which DHCS pays the monthly premiums of Medicare Part B for MediCal customers who are 65 years or older blind disabled or who have chronic renal disease BuyIn Process at Application At Intake identify applicants who are potentially eligible for BuyIn and provide the following information required for processing by DHCS If the Applicant Then Is not a current Medicare Verbally inform the applicant of their responsibility to apply recipient for Medicare Send the MC 355 to inform the applicant of the requirement to apply for Medicare during open enrollment Jan Mar Allow the applicant 60 days during open enrollment to apply for Medicare and allow for good cause if the SSA does not adjudicate the application within 60 days Note Individuals with a SOC are not required to apply for Part B unless they are MSP eligible Is currently receiving Enter Medicare information in CalWIN Medicare Refuses to apply for Medicare Discontinue individual with timely notice or after 60 days has not provided or been notified of an SSA caused delay BuyIn Process for Continuing Cases The MediCal Eligibility Data System MEDS generates a message for every MediCal customer when they reach age 64 and 9 months Initiate collection of BuyIn information for a MediCal customer by Sending the MC 355 to inform the beneficiary of the requirement to apply for Medicare Following up 60 days later to verify the beneficiary has applied County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Number Page 1504 3 of 4 Entering Medicare information in CalWIN BuyIn Problems Medicare BuyIn problems must be reported electronically to the BuyIn Cost Avoidance Unit BICAU using the State Medicare BuyIn Problem report form located on the DHCS website at dhcscagovbuyin Refer to MediCal Processing Guide 38 for instructions on completing the online fillable form D Medicare Part D Coverage Medicare Part D provides prescription drug coverage to eligible Medicare customers through private Prescription Drug Plans PDPs The PDP may be one of the following Feeforservice PDP operated by a private prescription drug provider Medicare AdvantagePrescription Drug Plan MAPDP operated by a Managed Care Medicare provider Dual eligible customers who are eligible to both MediCal and Medicare must use a Medicare Part D PDP to obtain most of their prescription drugs A Treatment Authorization Request TAR may be required when requesting MediCal coverage for prescription drugs that are not covered by Medicare Part D Enrollment Enrollment in Medicare Part D is voluntary for most Medicare beneficiaries Dual eligibles and MSP eligibles will be automatically enrolled into a PDP if they do not voluntarily choose one These include Medicare beneficiaries that are Dual Eligible MSP Eligible Zero SOC MediCal QMB SOC MediCal and the SOC has been paid SLMB SSI QI Dual eligibles that belong to a Medicare Advantage MA plan will be automatically enrolled into the MAPDP if a different plan is not selected Refer customers with questions regarding the PDP to which they have been enrolled to Medicare at 18006334227 Refer customers who need help determining which plan best meets their prescription needs to the Health Insurance Counseling and Advocacy program HICAP at 18004340222 Costs Medicare Part D includes the following costs which Medicare customers may have to pay depending on their income and resources A monthly premium An annual deductible Prescription drug copayments Other prescription drug costs not covered by Medicare Part D County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Medicare Number Page 1504 4 of 4 Deductions The monthly premium payment if paid outofpocket by a MediCal customer is treated as an other health care deduction The premium may vary depending on the PDP All other Medicare Part D costs that are paid out of pocket can be applied to the SOC for MediCal customers who have one Low Income Subsidy LIS LIS provides a subsidy for costs of premiums deductibles and copays otherwise owed by Part D customers Eligibility to LIS is determined by DHCS or the SSA The Daily LIS Application Report contains LIS customers identified in the MEDS who must be evaluated for MediCal andor MSP Review and process the report daily Complete instructions for processing cases on the DAILY LIS Application Report are available in MediCal Processing Guide 9 Procedure CalWIN How To 442 MediCal Processing Guide 38 MediCal Processing Guide 09 References ACWDLs 1115 1708 2026 and 1913 Sunset Date This policy will be reviewed for continuance on or by 8312024 Approval for Release Rick Wanne Director SelfSufficiency Services