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) and SSI 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) may act as an application for Medicare Savings Programs (QMB, SLMB, SLMB+, and QDWI).  It also provides that the resource limits used for the Low Income Subsidy (LIS) program shall also apply to Medicare Savings Programs.

 

Starting January 1, 2010, LIS applications received and processed by the SSA from residents of Alaska will generate an electronic referral to DPA.  Using information from this referral, DPA 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 programs for which the individual may qualify.

 

 580 A.      QUALIFIED MEDICARE BENEFICIARIES ( QMB )

 

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:

 

 

 

 

 

1. QMB Financial Eligibility

 

The financial determination for this category is done in accordance with the APA 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 rules is required and the poverty level based income standard for a household of two is used.

 

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

  

SSA COLA Disregard:  The January 1 cost of living allowance ( COLA ) increases in Social Security Title II benefits are disregarded in determining income eligibility for QMB 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/ QMB Eligibility

 

An individual who is otherwise Medicaid eligible (due to receipt of APA or eligible under an APA-related Medicaid category) and who also meets the criteria of QMB eligibility is considered to have dual APA/ QMB eligibility.  Any person who is eligible for APA-related Medicaid whose income does not exceed 100% of the federal poverty guidelines for Alaska is eligible for dual APA/ QMB coverage.  A dual eligible individual is entitled to full Medicaid coverage plus the coverage that comes with QMB eligibility.   QMB 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 need standards are currently higher than 100% of poverty (except for couples, one ineligible) and resource standards are the same as SSI.  Despite the higher need standards, most of the APA caseload still falls below 100% FPG and, therefore, are eligible for QMB coverage.  Only those with income over 100% of poverty are ineligible for QMB coverage.

 

3. QMB Eligibility Effective Date

 

The effective date of benefits for QMB 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 benefits and found eligible on April 15 will be eligible to begin receiving QMB benefits effective May 1.  This effective date applies to an individual dually eligible for APA and QMB as well as those eligible only for QMB coverage.

 

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

 

Example 1:  No Break in QMB Coverage:

An ongoing APA/QMB 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/QMB coverage beginning in January.  Since benefits were not interrupted, there is no break in the recipient's eligibility for APA or QMB coverage.

 

Example 2:  Break in QMB Coverage:

An ongoing APA/QMB recipient is scheduled for an annual eligibility review in December.  APA/QMB 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 benefits beginning January 5, the date of the review application.  However, QMB coverage cannot resume until February (the month after QMB eligibility was redetermined).

 

4. EIS Information

 

EIS INFORMATION

QMB ONLY ELIGIBILITY

Eligibility Code:

67

QMB-only

Medicaid Subtype:

QM

 Eligible only as QMB

 

DUAL APA/ QMB ELIGIBILITY

Eligibility Code:

69

Dual APA/ QMB

Medicaid Subtype:

**

Use the subtype appropriate for the type of APA or APA-related coverage the individual receives (SI, ST, NH, etc.).

 

  

580 B.      SPECIAL LOW INCOME MEDICARE BENEFICIARY ( SLMB AND SLMB PLUS)  

 

An individual who meets all of the eligibility requirements for the QMB category, except for income, may be entitled to payment of their Medicare Part B premium.  Unlike QMB coverage, SLMB coverage does not pay Medicare Part A premiums, deductibles, and coinsurance.   An individual who qualifies for SLMB or SLMB 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 COLA Disregard: The January 1 cost of living ( COLA ) increases in Social Security Title II benefits are disregarded in determining income eligibility for SLMB 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 ) are effective April 1 of each year.   

 

1. SLMB Base

 

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

 

2. SLMB Plus  

 

The SLMB 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 Base category and the SLMB Plus category (aside from the income standard) is that SLMB 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-Plus until the annual spending limit is reached.  Once the spending limit is reached, three things happen:

 

 

If spending reaches the annual limit before the end of the calendar year, monthly eligibility determinations for existing SLMB Plus recipients will continue to use the SLMB 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 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 Plus in the next calendar year, as explained below.

 

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

 

 

 

 

 

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

 

3. EIS Information   

 

The service that a SLMB Base or SLMB 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.

 

EIS INFORMATION

Eligibility Code:

68

SLMB – eligible for Part B payment only

78

SLMB Plus – eligible for Part B payment only

Medicaid Subtype:

SL

Eligible only as a Special Low Income Medicare Beneficiary or SLMB Plus

 

 

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 )

 

An individual who loses their SSA 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:

 

 

 

 

 

 

1. Reviews/Changes

 

Eligibility for QDWI 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 is required to act upon all reported changes received either from the recipient or through other channels.  APA timely and adequate notice requirements apply to termination of benefits.

 

 

2. EIS Information

 

The service that a QDWI 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.  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.

 

 

EIS INFORMATION

Eligibility Code:

66

QDWIOnly

Medicaid Subtype:

QD

Eligible only as a Qualified Disabled and Working Individual

Household Type

QD1

One person household (200% FPG )

QD2

Two person household (200% FPG )

 

  

580 D.      LOW-INCOME SUBSIDY (LIS) PROGRAM

 

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 ( MMA ) 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) 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 and do not need to apply.  This includes Qualified Medicare Beneficiaries ( QMB ), Special Low-Income Medicare Beneficiaries ( SLMB and SLMB Plus), and Qualified Disabled and Working Individuals ( QDWI ).

 

1. Taking the LIS Application

 

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

 

DPA staff may assist individuals with completing the application for the subsidy and forward it to SSA.  When submitting the application to SSA, follow the instructions below:

 

 

 

 

 

Mail the LIS application form to:

 

Social Security Administration

Wilkes-Barre Data Operations Center

PO Box 1020

Wilkes-Barre, PA  18767-9910

 

2. When DPA Processes the Application

 

If an individual insists that DPA make the LIS eligibility determination, The DPA 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 has two basic levels of assistance.

 

 

 

 

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

 

 

 

 

 

 

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

 

4. LIS Premium Payment Limits

 

In order to get Medicare Part D coverage, the individual must enroll in a prescription drug plan ( PDP ). The prescription drug benefit is provided through private stand-alone PDP's. 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 is limited.  See Addendum 1 the standard premium rate that the LIS 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 Information

 

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

 

 

EIS INFORMATION

Program Type on REAP Screen

GA

LIS Application  (Y)

Subsidy Level on LISA Screen

0

Income at 150% FPG

25

Income at 146% and up to149% FPG

50

Income at 141% and up to145% FPG

75

Income at 136% and up to 140% FPG

100

Income at or below 135% FPG

 

 

 

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