580           MEDICARE PREMIUM ASSISTANCE CATEGORIES

The Medicaid program provides assistance with the cost of Medicare premiums, deductibles, and coinsurance.  These Medicare assistance categories generally use the financial and non-financial eligibility criteria of the Adult Public Assistance (APA Adult Public Assistance) and SSI Supplemental Security Income programs, except that the income and resource limits are higher.

The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 provides that applications for the Low Income Subsidy program (also known as Extra Help) administered by the Social Security Administration (SSA Social Security Administration) may act as an application for Medicare Savings Programs (QMB Qualified Medicare Beneficiaries, SLMB Special Low Income Medicare Beneficiaries, SLMB Special Low Income Medicare Beneficiaries+, and QDWI Qualified Disabled and Working Individuals).  It also provides that the resource limits used for the Low Income Subsidy (LIS Low Income Subsidy) program shall also apply to Medicare Savings Programs.

Starting January 1, 2010, LIS Low Income Subsidy applications received and processed by the SSA Social Security Administration from residents of Alaska will generate an electronic referral to DPA Division of Public Assistance.  Using information from this referral, DPA Division of Public Assistance will send an application form to the individual on which they may provide information needed to determine eligibility for Medicare Savings Programs or other Medicaid categories.  The application form may also be used to apply for other DPA Division of Public Assistance programs for which the individual may qualify.

 580 A.      QUALIFIED MEDICARE BENEFICIARIES ( QMB Qualified Medicare Beneficiaries )

An individual who meets all of the following criteria is eligible for payment of his or her Medicare Part A and Part B premiums, deductibles, and coinsurance:

• Is entitled to enroll in Medicare Part A (hospital insurance);

• Has income that does not exceed 100% FPG Federal Poverty Guidelines ;

• Has resources that do not exceed the amount listed in Addendum 1; and

• Meets the nonfinancial requirements for SSI Supplemental Security Income /APA Adult Public Assistance-related Medicaid (i.e., filing an application, Social Security number, citizenship, residency, assignment of rights).

1. QMB Qualified Medicare Beneficiaries Financial Eligibility

The financial determination for this category is done in accordance with the APA Adult Public Assistance methodology except for those requirements that are prohibited by the Medicaid program as described in Sections 523 and 524.  For a couple case in which one person is eligible and one is ineligible, spousal deeming according to SSI Supplemental Security Income rules is required and the poverty level based income standard for a household of two is used.

As in APA Adult Public Assistance income determinations, countable income is used to determine financial eligibility.  Countable income is total gross income (not including SSI Supplemental Security Income and APA Adult Public Assistance payments), less allowable disregards.

SSA Social Security Administration COLA Cost of Living Allowance Disregard:  The January 1 cost of living allowance ( COLA Cost of Living Allowance ) increases in Social Security Title II benefits are disregarded in determining income eligibility for QMB Qualified Medicare Beneficiaries until the annual federal poverty guidelines for Alaska are implemented.  Usually, this means that COLAs are disregarded through March since the new poverty guidelines are effective April 1 of each year.   

2. Dual APA Adult Public Assistance/ QMB Qualified Medicare Beneficiaries Eligibility

An individual who is otherwise Medicaid eligible (due to receipt of APA Adult Public Assistance or eligible under an APA Adult Public Assistance-related Medicaid category) and who also meets the criteria of QMB Qualified Medicare Beneficiaries eligibility is considered to have dual APA Adult Public Assistance/ QMB Qualified Medicare Beneficiaries eligibility.  Any person who is eligible for APA Adult Public Assistance-related Medicaid whose income does not exceed 100% of the federal poverty guidelines for Alaska is eligible for dual APA Adult Public Assistance/ QMB Qualified Medicare Beneficiaries coverage.  A dual eligible individual is entitled to full Medicaid coverage plus the coverage that comes with QMB Qualified Medicare Beneficiaries eligibility.   QMB Qualified Medicare Beneficiaries coverage includes payment of Medicare Part A premiums, payment of Part A and Part B deductibles and coinsurance, and payment of services covered by Medicare but not by Alaska's Medicaid program, such as podiatrist and hospice services.

Note:  

The APA Adult Public Assistance need standards are currently higher than 100% of poverty (except for couples, one ineligible) and resource standards are the same as SSI Supplemental Security Income.  Despite the higher need standards, most of the APA Adult Public Assistance caseload still falls below 100% FPG Federal Poverty Guidelines and, therefore, are eligible for QMB Qualified Medicare Beneficiaries coverage.  Only those with income over 100% of poverty are ineligible for QMB Qualified Medicare Beneficiaries coverage.

3. QMB Qualified Medicare Beneficiaries Eligibility Effective Date

The effective date of benefits for QMB Qualified Medicare Beneficiaries coverage is the beginning of the month after the month in which the eligibility determination is made.  For example, an individual applying on March 30 for QMB Qualified Medicare Beneficiaries benefits and found eligible on April 15 will be eligible to begin receiving QMB Qualified Medicare Beneficiaries benefits effective May 1.  This effective date applies to an individual dually eligible for APA Adult Public Assistance and QMB Qualified Medicare Beneficiaries as well as those eligible only for QMB Qualified Medicare Beneficiaries coverage.

Eligibility for QMB Qualified Medicare Beneficiaries benefits must be redetermined every 12 months and may be set to coincide with the APA Adult Public Assistance review date for individuals who are dually eligible.  

Example 1:  No Break in QMB Qualified Medicare Beneficiaries Coverage:

An ongoing APA Adult Public Assistance/QMB Qualified Medicare Beneficiaries recipient is scheduled for an annual eligibility review in December.  The review application is received timely on December 5, and the recipient's eligibility is redetermined on December 15. The recipient is determined eligible for continued  APA Adult Public Assistance/QMB Qualified Medicare Beneficiaries coverage beginning in January.  Since benefits were not interrupted, there is no break in the recipient's eligibility for APA Adult Public Assistance or QMB Qualified Medicare Beneficiaries coverage.

Example 2:  Break in QMB Qualified Medicare Beneficiaries Coverage:

An ongoing APA Adult Public Assistance/QMB Qualified Medicare Beneficiaries recipient is scheduled for an annual eligibility review in December.  APA Adult Public Assistance/QMB Qualified Medicare Beneficiaries eligibility ended on December 31 because a review application was not received by the end of December.  An untimely review was subsequently received on January 5, and the recipient's eligibility for assistance was redetermined on January 15. The recipient is found eligible for APA Adult Public Assistance benefits beginning January 5, the date of the review application.  However, QMB Qualified Medicare Beneficiaries coverage cannot resume until February (the month after QMB Qualified Medicare Beneficiaries eligibility was redetermined).

4. EIS Eligibility Information System Information

580 B.      SPECIAL LOW INCOME MEDICARE BENEFICIARY ( SLMB Special Low Income Medicare Beneficiaries AND SLMB Special Low Income Medicare Beneficiaries PLUS)  

An individual who meets all of the eligibility requirements for the QMB Qualified Medicare Beneficiaries category, except for income, may be entitled to payment of their Medicare Part B premium.  Unlike QMB Qualified Medicare Beneficiaries coverage, SLMB Special Low Income Medicare Beneficiaries coverage does not pay Medicare Part A premiums, deductibles, and coinsurance.   An individual who qualifies for SLMB Special Low Income Medicare Beneficiaries or SLMB Special Low Income Medicare Beneficiaries Plus is also eligible for Medicare Part D prescription drug coverage, without having to pay a premium or deductible.  See Addendum 6 - Medicare Part D Low Income Subsidy Guide.

SSA Social Security Administration COLA Cost of Living Allowance Disregard: The January 1 cost of living ( COLA Cost of Living Allowance ) increases in Social Security Title II benefits are disregarded in determining income eligibility for SLMB Special Low Income Medicare Beneficiaries until the annual federal poverty guidelines for Alaska are implemented.  This means that COLAs are usually disregarded through March since the new poverty guidelines ( FPG Federal Poverty Guidelines ) are effective April 1 of each year.   

1. SLMB Special Low Income Medicare Beneficiaries Base

Specified Low Income Medicare Beneficiary ( SLMB Special Low Income Medicare Beneficiaries ) is for individuals or couples with a base income limit of less than 120% of the federal poverty guideline for Alaska.  SLMB Special Low Income Medicare Beneficiaries applicants may qualify for up to three months of retroactive eligibility.   

2. SLMB Special Low Income Medicare Beneficiaries Plus  

The SLMB Special Low Income Medicare Beneficiaries Plus category is for individuals or couples with an income limit of less than 135% of the federal poverty guideline for Alaska.  The difference between the regular SLMB Special Low Income Medicare Beneficiaries Base category and the SLMB Special Low Income Medicare Beneficiaries Plus category (aside from the income standard) is that SLMB Special Low Income Medicare Beneficiaries Plus is a capped entitlement under federal law.  This means there is an annual limit on the amount of money available to pay for the expanded eligibility category.

All individuals applying for coverage of their Part-B premiums will have their eligibility determined for SLMB Special Low Income Medicare Beneficiaries-Plus until the annual spending limit is reached.  Once the spending limit is reached, three things happen:

• Staff will be notified via broadcast with instructions;
   

• Eligibility determinations for new applicants revert back to the SLMB Special Low Income Medicare Beneficiaries Base category; and
   

• Retroactive SLMB Plus coverage is no longer available.

If spending reaches the annual limit before the end of the calendar year, monthly eligibility determinations for existing SLMB Special Low Income Medicare Beneficiaries Plus recipients will continue to use the SLMB Special Low Income Medicare Beneficiaries Plus criteria, as the spending on these individuals has already been charged against the annual limit.  Any new eligibility determination must be made under the SLMB Special Low Income Medicare Beneficiaries Base category.  If staff are notified that the annual spending limit has been reached, caseworkers must send an email to DPAPolicy@alaska.gov with information (e.g. client name, ID number, the household size), and the countable income of an individual who would have been eligible under the 135% level.  These individuals will be given preference over any new applicants for SLMB Special Low Income Medicare Beneficiaries Plus in the next calendar year, as explained below.

Beginning in January of each year, eligibility determinations return to using the SLMB Special Low Income Medicare Beneficiaries Plus criteria.  Because of the limited funding, eligibility determinations will be made in the following order:   

• Individuals who were SLMB Special Low Income Medicare Beneficiaries Plus recipients in the previous calendar year;

• Individuals who applied for SLMB Special Low Income Medicare Beneficiaries Plus in the previous calendar year, but who were denied because that year’s annual cap had been reached;

• New applicants in the current calendar year; and

•  New applicants for retroactive coverage in the current calendar year.  

Retroactive Coverage Limit:  For a current year applicant, retroactive SLMB Special Low Income Medicare Beneficiaries Plus coverage may not cover any months prior to January.  

3. EIS Eligibility Information System Information   

The service that a SLMB Special Low Income Medicare Beneficiaries Base or SLMB Special Low Income Medicare Beneficiaries Plus receives is limited to payment of their Part B Medicare premium, which is accomplished by data transfer between the Division of Health Care Services and Social Security Administration.  The Recipient Identification Card will reflect this by containing the following statement:

For record purposes only.  Not valid for Medicaid services.  This authorizes the State of Alaska to pay only the Medicare Part B premium for the person/s listed above.

4. Benefit Start Date

SLMB benefits begin the month of application.  In addition, the applicant may request three months of retroactive SLMB coverage.  In order to qualify for retroactive SLMB, the applicant must meet all eligibility factors in the months requested.

580 C.      QUALIFIED DISABLED AND WORKING INDIVIDUALS ( QDWI Qualified Disabled and Working Individuals )

An individual who loses their SSA Social Security Administration disability benefits because of earnings from work, but who continue to have the disabling condition, may continue to receive Medicare coverage if they continue pay the premiums.  Under this eligibility category, Medicaid will pay the Medicare Part A premium only.  To be eligible for this category, an individual must:

• Be entitled to enroll in Medicare Part A (hospital) insurance;

• Have income, as determined by APA methodology that does not exceed 200% of the federal poverty guidelines for Alaska.  See Addendum 1;

• Have resources that do not exceed twice the SSI resource limit ($4,000 for an individual and $6,000 for a couple);

• Meet the nonfinancial requirements for SSI Supplemental Security Income /APA Adult Public Assistance-related Medicaid (i.e., filing an application, enumeration, citizenship, residency, assignment of rights); and

• Not be eligible for any other Medicaid category.

1. Reviews/Changes

Eligibility for QDWI Qualified Disabled and Working Individuals must be reviewed every 12 months.  At that time the recipient is required to submit a review application (GEN 72).  Additionally, recipients are required to report any changes in their circumstances, as all eligibility criteria must be met each month.  DPA Division of Public Assistance is required to act upon all reported changes received either from the recipient or through other channels.  APA Adult Public Assistance timely and adequate notice requirements apply to termination of benefits.

2. EIS Eligibility Information System Information

The service that a QDWI Qualified Disabled and Working Individuals receives is limited to payment of their Part A Medicare premium, which is accomplished by data transfer between the Division of Health Care Services and SSA Social Security Administration.  The Recipient Identification Card will reflect this by containing the following statement:

This authorization is valid only for the State of Alaska to pay the above person's Medicare Part A premium.  It is not valid for payment of any medical services.

580 D.      LOW-INCOME SUBSIDY (LIS Low Income Subsidy) PROGRAM

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 ( MMA Medicare Modernization Act ) established a subsidy program that provides extra help with Medicare Part D premiums, deductibles, and co-payments. (See Section 506 for more information about Medicare Part D.)  This Low-Income Subsidy (LIS Low Income Subsidy) program is available to Medicare beneficiaries beginning January 1, 2006.

Note:

Medicaid recipients who are Medicare eligible are automatically eligible for and enrolled in the LIS Low Income Subsidy and do not need to apply.  This includes Qualified Medicare Beneficiaries ( QMB Qualified Medicare Beneficiaries ), Special Low-Income Medicare Beneficiaries ( SLMB Special Low Income Medicare Beneficiaries and SLMB Special Low Income Medicare Beneficiaries Plus), and Qualified Disabled and Working Individuals ( QDWI Qualified Disabled and Working Individuals ).

1. Taking the LIS Low Income Subsidy Application

The Social Security Administration (SSA Social Security Administration) has primary responsibility for determining eligibility for the LIS Low Income Subsidy.  DPA Division of Public Assistance will make an LIS Low Income Subsidy eligibility determination only if the applicant specifically requests a state determination.  Medicare beneficiaries must apply for the Low-Income Subsidy (LIS Low Income Subsidy) using the SSA Social Security Administration-1020 form, Application for Help with Medicare Prescription Drug Plan Costs.  

DPA Division of Public Assistance staff may assist individuals with completing the application for the subsidy and forward it to SSA Social Security Administration.  When submitting the application to SSA Social Security Administration, follow the instructions below:

• Do not photocopy the SSA Social Security Administration-1020 form.  SSA Social Security Administration electronically scans these applications and photocopying makes the form unscannable, which could delay an SSA Social Security Administration decision.  

• Do not date-stamp.  Enter a hand-written date in the For Official Use Only box using MM/DD/YYYY format.

• Do not fold the application other than where it is pre-folded.  Additional folds may affect scanning.

• Do not send any additional material with the application.  SSA will contact the individual if more information is needed.

Mail the LIS Low Income Subsidy application form to:

Social Security Administration

Wilkes-Barre Data Operations Center

PO Box 1020

Wilkes-Barre, PA  18767-9910

2. When DPA Division of Public Assistance Processes the Application

If an individual insists that DPA Division of Public Assistance make the LIS Low Income Subsidy eligibility determination, The DPA Division of Public Assistance office must register the application, and then forward it to the Senior Benefits Office at:

Alaska Senior Benefits Program
855 W. Commercial Drive
Wasilla, AK  99654

Refer to Chapter 126 of the Administrative Procedures Manual for more detailed instructions.

3. Subsidy Levels

The LIS Low Income Subsidy has two basic levels of assistance.

1. • Full Subsidy - is for individuals with annual incomes below 135% of the Federal Poverty Guidelines (FPG) and countable assets below $8,580 for individuals and $13,620 for couples.  These individuals pay no premium, no deductible, and small co-payments.

1. • Reduced Subsidy - is for individuals with annual incomes below 135% of the FPG and countable assets between $8,580 and $13,300 for individuals and between $13,620 and $26,580 for couples.  These individuals pay no premium, a $66 deductible, 15% co-insurance up to $4,750 out-of-pocket costs, and small co-payments after that.

1. • Reduced subsidy also includes individuals with annual incomes between 135% and 150% FPG and countable assets below $13,300 for individuals and $26,580 for couples. These individuals pay a sliding-scale premium, a $66 deductible, 15% co-insurance up to $4,750 out-of-pocket costs, and small co-payments after that.  See Addendum 6.

The level of annual income determines the amount of the subsidy.

1. • Income at or below 135%FPG qualifies for a 100% premium subsidy.

1. • Income at 136%and up to 140%FPG qualifies for a 75% premium subsidy.

1. • Income at 141%and up to 145%FPG qualifies for a 50% premium subsidy.  

1. • Income at 146%and up to 149%FPG qualifies for a 25% premium subsidy.  

1. • Income at 150%FPG qualifies for a 0% premium subsidy.   

See Addendum 1 for the current annual federal poverty guidelines for Alaska.

4. LIS Low Income Subsidy Premium Payment Limits

In order to get Medicare Part D coverage, the individual must enroll in a prescription drug plan ( PDP Prescription Drug Plan ). The prescription drug benefit is provided through private stand-alone PDP'sprescription drug plans. Each plan will contract with certain pharmacies, and may have different costs.  There are seventeen organizations that have plans available in Alaska.  See Addendum 7 - Prescription Drug Plans Available in Alaska.

The maximum amount of the Medicare Part D premium covered by the LIS Low Income Subsidy is limited.  See Addendum 1 the standard premium rate that the LIS Low Income Subsidy will cover in Alaska.  If an individual chooses a plan that has a premium in excess of this amount, the individual must pay the difference.

5. EIS Eligibility Information System Information

The Low-Income Subsidy Assistance Application (LISA) screen is used when DPA Division of Public Assistance make the LIS Low Income Subsidy eligibility determination.