Medicare Savings Program
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Medicare Savings Program

Revised April 25, 2008

Purpose:

Key Points of Medicare Savings Program 

Income Calculation - Spouse in the Home

Both Applying and ABD Relatable

With Non-Applying or Non-Relatable Spouse (N / NS)

Medicare Buy-In - Part B

QDWI- Medical Coverage Group - S04

QI-1 - Medical Coverage Group - S06

QMB- Medical Coverage Group - S03

SLMB- Medical Coverage Group - S05

TPL- Third Party Liability Screens - Coding

 

Key Points of Medicare Savings Program

  • Medicare Savings Program refers to the programs designed to help clients pay for Medicare premiums, deductibles, and co-insurance.

  • It is very important for both eligibility and for federal match funding that any client eligible for and receiving Medicare Part A has an AU opened in ACES so that premiums, co-payment, and deductibles are covered when they should be.

  • The medical coverage groups that pay these are:

S03 = Qualified Medicare Beneficiary (QMB)

S04 = Qualified Disabled Working Individual (QDWI)

S05 = Specified Low Income Medicare Beneficiary (SLMB)

S06 = Qualified Individuals (QI-1 )

  • A client eligible for Medicaid is not automatically eligible for Medicare Savings Program assistance.

  • However, in most situations if a client is receiving SSI and / or A, B, or D related Medicaid they will be eligible for Medicare Savings Program assistance.

  • The exception to this would be a client receiving A, B, or D related S99 Medicaid and has income over the QMB, QDWI, or SLMB income / resource standard.

  • Regardless of whether the client is receiving only Medicare Savings Program assistance, or is dually eligible and receiving Medicaid in addition to QMB, SLMB, or QDWI, a separate medical AU must be opened for correct benefits to be paid.

This includes clients receiving SSI and active on a medical coverage group S01.

  • Any program that has eligibility based on Medicare Part A must have a [Y] entered in the MEDICARE PART A field on the (CIRC) during screening, and a [Y] entered in the MEDICARE PART A field on the (DEM2).
     

Income Calculation - Spouse in the Home

  • When both the ABD related person and their spouse are applying for QMB / SLMB enter FINL RESP code [PN] on the( STAT )  for both people.

  • If application is made for both people enter [PN] on the ( STAT ) even if the ABD related person's spouse is not ABD relatable.

  • ACES will determine eligibility correctly and deny the ineligible spouse if not ABD related, changing their FINL RESP code appropriately.

  • When the ABD-related person's spouse is not applying, enter FINL RESP code [SP].

  • QMB and SLMB are both CN medical programs for which there is no MN component. Because of this only CN deeming rules are used to determine eligibility.

See EA-Z Manual - WAC 388-517-0310  Eligibility for federal Medicare savings and state-funded Medicare buy-in programs.

Based on FINL RESP codes, income, resources, age, and disability information ACES determines eligibility as follows:

  1. Both applying and ABD relatable :

  1. When both applicants are ABD related, and both are applying, ACES uses the 2-person standard and considers income and resources jointly.

  2. If the net income is over the appropriate QMB standard ACES looks at SLMB eligibility. If the net income is over the applicable SLMB standard ACES denies the AU.

  1. With non-applying or non-relatable spouse (N / NS):

  1. When the ABD related person's spouse is not applying for or not relatable to ABD ( N / NS ) and no income is deemed from the spouse, ACES uses a 1-person standard and considers only the ABD related person's income and resources.

  1. When the ABD related person's spouse is N / NS and income is deemed from the spouse, ACES uses a 2-person standard and considers the ABD related person's income and resources plus any deemed income.

  2. This income deeming rule looks at whether or not the N / NS spouse has net income over one-half the FBR (Federal Benefit Rate). It deems 0 if under and deems the entire amount if over.

  3. If the net income (including deemed income, if applicable) is over the appropriate QMB standard (100% of FPL - Federal Poverty Level) ACES looks at SLMB eligibility.

  4. If the net income is over the applicable SLMB standard (120% of FPL) ACES looks at eligibility for QI-1. If the net income is over the applicable QI-1 standard (135% of FPL) ACES denies the AU.  See Medicare Savings Program- QI-1-Medical Coverage Group S06.
     

Medicare Buy-In - Part B

  • Clients who receive Medicaid and receive or are eligible for Medicare Part B are accreted to the Buy-In system automatically through an interface with MMIS.

  • The state then pays their premiums out of state-only dollars.

  • The process assumes that the client is not eligible for QMB, SLMB, or QI-1.

  • Under State-funded Buy-In, it is not necessary to create a new medical coverage group for eligibility.

  • The Medicaid medical coverage group is sufficient but a (TPL1) must be completed.  See Medicare Savings Program -TPL-Third Party Liability Screens - Coding.
     

QDWI - Medical Coverage Group - S04

  • Eligibility for QDWI (Qualified Disabled and Working Individuals Program) begins the first of the month the client becomes eligible for Part A coverage.

  • QDWI pays Medicare Part A premiums only.

  • No MAID is generated.

  • QDWI does not pay co-payments or deductibles.

  • The user can do retroactive coverage for up to three months prior to the month of application.

  • One (TPL1) screen for Part A.

  • The certification period for QDWI is twelve (12) months.
     

QI-1 - Medical Coverage Group - S06

  • Eligibility for QI-1 (Qualified Individuals), formerly known as ESLMB, begins the first of the month the client becomes eligible for Part B coverage.

  • To be eligible for QI-1 a person cannot be otherwise eligible for categorically needy ( CN ) or medically needy ( MN ) coverage.

  • QI-1 pays Medicare Part B premiums only.

  • Need one (TPL1) for Part B.

  • No MAID is generated.

  • QI-1 does not pay co-payments or deductibles.

  • The user can do retroactive coverage for up to three months prior to the month of application, as long as the client was enrolled in Part A.

  • If an QI-1 AU is active and a user tries to finalize a spenddown AU the Edit Message 1849 – Must Close S06 AU Prior to Spenddown Activation - displays at the bottom of the screen.

  • If adding a program, or a case trickles to S06, a client active in another MA AU will be denied for Reason Code 288 - Ineligible QI-1 Already Receiving MA.

  • The certification period for QI-1 cases is until December 31st of each year or until the date that the annual allotment of federal funds is exhausted.

The exception to this is if the client is applying and the ongoing month is December of the current year. In this case the certification period is through December of the next year.

  • If the federal funding has been exhausted ACES will not allow approval of an QI-1 assistance unit. The case will be denied with Reason Code 388 - WA Funds CAP for QI-1 Already Reached.
     

QMB - Medical Coverage Group - S03

  • Eligibility for QMB (Qualified Medicare Beneficiary Program) begins the first of the month following the month eligibility is determined for the program.

  • QMB pays Medicare Part A and B premiums, co-insurance, and deductibles.

  • A QMB MAID is generated if the client is not receiving any other type of medical assistance.

  • If the client is receiving medical assistance (dual eligible) the MAID for the other medical program indicates the client is eligible for QMB.

  • There is no retroactive coverage for QMB.

  • If Medicaid eligibility is authorized and for some reason an S03 AU is not opened for the QMB eligible client, process add a program.  See Add a Program and Long Term Care, Alternate Care, & Waivered Services

  • Effective 11/01/00 all clients active in a LTC AU are eligible to receive QMB.

  • When a case is screened that is potentially eligible for QMB the S03 medical coverage group will display on (INCH) as an option to remind workers to process the QMB AU.

  • The certification period for QMB is twelve (12) months.

SLMB - Medical Coverage Group - S05

  • Eligibility for SLMB (Specified Low Income Medicare Beneficiary Program) begins the first of the month the client becomes eligible for Part B coverage.
  • SLMB pays for Medicare Part B premiums only.
  • No MAID is generated.
  • SLMB does not pay co-payments or deductibles.
  • The user can do retroactive coverage for up to three months prior to the month of application as long as the client was enrolled in Part A.
  • Need one (TPL1) for Part B.
  • The certification period for SLMB is twelve (12) months.

TPL - Third Party Liability Screens - Coding

  • TPL screens completed by CSO /HCS workers for clients who receive Medicare Savings Program (MSP) benefits must be completed correctly.

  • To identify Medicare Part A entitlement, do the following:

  1. Go to the ACES (WMEN) screen.

  2. Select [Y] for State Online Query (SOLQ).

  3. Go to the (SSA2) screen for Medicare Entitlement information.

  • To complete the (TPL1) screens take the following actions:

  1. Go to the (DEM2) screen of the eligible person and press <F22> to access the (TPL1) screen.

  2. Code two (TPL1) screens, one for Medicare Part A and one for Medicare Part B. (See chart below).

  • When a client does not have both Part A and Part B, users should complete the single TPL screen and report these cases to Elliott Paskus (paskues@dshs.wa.gov) at HRSA.

  • If you have technical problems when you are creating the TPL screens, contact IT Solutions Customer Support at 360-664-4560.

Complete the TPL1 Screen as follows:

(TPL1) Screen Field

MEDICARE PART A

MEDICARE PART B

Carr Code

MEDA

MEDB

Policy Effective Date – From

Obtain enrollment date from Medicare card, SOLQ SSA2, or Bendex.

Obtain enrollment date from Medicare card, SOLQ SSA2, or Bendex.

Policy Effective Date – To

If currently receiving Medicare leave blank

If currently receiving Medicare leave blank

Policy Number (Medicare Claim Number)

Obtain number from Medicare card, SOLQ SSA1, or Bendex.

Obtain number from Medicare card, SOLQ SSA1, or Bendex.

Paid By

If BIC is M, leave blank; if BIC is anything else enter [MA].”MA” indicates a client has free Medicare Part A

Enter [WA] “WA” under Medicare Part B is required

NOTE: ACES interfaces may change the “Paid By” coding as a case progresses in the Buy-In system.

All MSP clients should have a letter suffix on their claim number. This is referred to as a Beneficiary Identification Code (BIC).

If the BIC is J or K, contact Elliott Paskus at HRSA.

You cannot use the BENDEX to verify Medicare eligibility for clients who have Railroad Retirement Board (RRB) income. Medicare eligibility information can be found at http://www.rrb.gov/lmo/conference/survivor/retandsurv/medicare.asp.  To identify the clients’ RRB office, use the client’s zip code at http://www.rrb.gov/accessrrbgov/ZipLocator/zip_enter.asp  or call 1-800-808-0772 and select Option 5.

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Modification Date: April 25, 2008
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