Medicare, Buy-In, QMB, SLMB and QI-1 April 6, 2005

Medicare ? What is Medicare Part A? Cost? What is Medicare Part B? Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits. Cost? Most people don’t have to pay a monthly payment, called a premium for Part A. This is because they or a spouse paid Medicare taxes while working. What is Medicare Part B? Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient care. It also covers some other medical services that part a doesn’t cover, such as some of the services of physical and occupational therapist, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare part B premium each month ($78.20 in 2005). This amount could be higher if you didn’t sign up for Part B when you first became eligible. You may also pay a $110.00 Part B deductible each year before Medicare starts to pay its share.

Part B Premium Payment Program {Buy-In} What is Part B Buy In? Buy-In refers to an agreement between the State and Federal governments in which the State uses Medi-Cal funds to pay the monthly Part B health coverage premiums for certain Medi-Cal recipients who are also eligible for Medicare. Although the eligibility requirements for Medi-Cal and Medicare are different, most Public Assistance (PA) and Medically Needy (MN) qualified persons, individuals 65 years of age or older, and blind or disabled individuals are eligible for the Medicare Buy-In Program. Buy-In Agreement California pays Part B premiums under a Buy-In agreement with the Health Care Financing Administration (HCFA). The benefit to the State in enrolling individuals in the Medicare Part B Buy-In Program is to pass along certain expenses to the Medicare Program, which would otherwise have to be paid by the Medi-Cal Program. All Medi-Cal recipients eligible for Medicare Part B coverage are required to participate in the Medicare Buy-In Program in accordance with Section 50777 of Title 22 of the California Code of Regulations. Part B Premium and Deductible The Part B Premium for 2005 is $78.20 per month per beneficiary. The premium amount may increase in January of each year as specified by the Secretary of Health and Human Services. In addition to the Part B premium, the State also pays the annual Part B deductible of $110.00 effective January 2005. How is Buy-In Funded? Under the Medicare Buy-In Program, the State uses Medi-Cal funds to pay the monthly Medicare Part B health coverage premiums for qualifying Medi-Cal recipients. After the State makes this premium payment, Medicare pays eighty percent (80%) of the reasonable costs of Medicare Part B covered services.

When Does Part B Coverage Begin MN Recipients Coverage begins the third month after the individual’s eligibility for Medi-Cal is approved, providing the individual is eligible for Part B coverage. Buy-In determination can be no earlier than the month of application and may be later. Example: 1. Applied for Medi-Cal April 2001 2. Approval Date May 2001 3. Medi-Cal Effective Date January 2001 (Retro) 4. Buy-In Effective Date July 2001 A client who is eligible for Medicare Part B and is a Medi-Cal recipient is automatically eligible to buy-in. If a client requests discontinuance of the Medi-Cal Program, please inform them that the Medicare Premium will be deducted from their Social Security check. 2005 Premium is $78.20.

Qualified Medicare Beneficiary (QMB) What is QMB? Federal Law defines a “qualified Medicare beneficiary” as an individual who is entitled to hospital insurance benefits under Part A of Subchapter XVIII; whose income does not exceed the official poverty line for a family of such size; and whose resources do not exceed twice the maximum amount of resources that an individual may have and obtain benefits under the SSI Program. Such individuals are eligible to receive, from the state, certain premiums under Subchapter XVIII (including Parts A and B), deductibles and coinsurance fees. If a client is already receiving “Buy-In” why do we screen for QMB? Although Medi-Cal “buys-in” for medically needy-only (MNOs) beneficiaries because it is cost effective, the Medi-Cal program currently does not receive Federal Financial Participation (FFP) for payment of Part B premiums for MNOs. Once the QMB program is implemented, however FFP will become available for the MNOs who are also eligible to QMB. This means that federal monies will pay the part B premium instead of the state – Buy-In Program. CDHS shall pay Medicare premiums, coinsurance, and deductibles. The Two Basic Groups of QMB eligibles are: Those receiving regular full scope Medi-Cal through cash aid, SSI or as MNOs. Those who do not want regular Medi-Cal or who are over the Medi-Cal resource level.

ISAWS User Manual Potentially Eligible The Four QMB Requirements Are: A QMB must be eligible for Medicare Part A (Hospital Insurance). A QMB must have income at or below the 100% FPL. A QMB must have property valued at $4000.00 or less if a single person or $6000.00 or less if married and living with a spouse. A QMB must meet certain other Medi-Cal program requirements such as California Residency. ISAWS User Manual Potentially Eligible Note: These steps are for an existing case. QMB 12-31-04 Step Screen Action 1 ISAWS MAIN MENU Select Application Entry 2 AEMENU Select Non-Financial Application Entry Menu – 2 3 AENFM2 Select Medicare Coverage

ISAWS will assign a Secondary Aid Code (80) for eligible members. Step Screen Action 4 AEMEDI If Then Y to Potentially Eligible to EDBC will use to determine Part A QMB Eligibility N to Potentially Eligible to System will not determine 5 AEEDBC Run EDBC Review results Authorize ISAWS will assign a Secondary Aid Code (80) for eligible members.

Note: These steps are for an existing case. SSI/SSP Note: These steps are for an existing case. Step Screen Action 1 ISAWS MAIN MENU Select Application Entry 2 AEMENU Select Non-Financial Application Entry Menu – 2 3 AENFM2 Select Medicare Coverage 4 AEMEDI If Then SSI/SSP Enter Y In The QMB Applied and Continue Not SSI/SSI Stop 5 Enter AEEDBC in Next Screen 6 AEEDBC Run EDBC Review results Authorize

Specified Low-Income Medicare Beneficiary (SLMB) What is SLMB? The Specified Low-Income Medicare Beneficiary (SLMB) Program was established under Public Law 101-508. A SLMB must be entitled to Medicare Part A, have no more than twice Medi-Cal's property limit, ($4,000 for one person, $6,000 for a couple); have income below 120% of the federal poverty level (FPL) and be a citizen or alien who would be eligible for full Medi-Cal benefits. A Specified Low-Income Medicare Beneficiary (SLMB) is ineligible as a Qualified Medicare Beneficiary (QMB) solely due to excess income. The SLMB Program is limited to the payment of the Medicare Part B premium.  It does not pay the Medicare Part A premium or the Part B deductibles or coinsurance.  The SLMB's Medicare Part B premium will be purchased under the State Buy-In process. A SLMB must be entitled to Part A Medicare hospital insurance benefits, meet the qualifying income level and meet the qualifying resource limit. The period of eligibility shall include the first month eligibility is approved, and may include three months of retroactive benefits from the month of application. If eligibility exists, the CDHS shall pay Medicare Part B premiums. SLMB Aid code is 8C and can be retroactive for 3 months.

ISAWS does not support the SLMB Program. The caseworker must screen for the SLMB Program manually if the individual fails for QMB. I recommend: The caseworker should print the failed QMB budget from ISAWS. Document the SLMB FPL and determine if the individual is eligible for SLMB. If the individual is eligible for SLMB the AID CODE will be 8C. The caseworker will need to override ISAWS and enter the secondary aid code. Then when you get to the screen below enter a “Y” in the override field for the secondary aid code for the eligible individual. This should trigger MEDS once authorized.

Qualifying Individual Program (QI-1) What is the QI-1 Program The Qualifying Individual (QI-1) Program is federally funded and established by Section 4732 of the Balanced Budget Act of 1997. The state receives yearly federal allocations to cover QI cost. The Program pays the Medicare part B Premium for eligible individuals and uses the same eligibility methodology as QMB and SLMB. The QI-1 Program pays for the Part B Premium The state will be reimbursed by federal funds for QI-1 eligibles. The Two Basic Groups of QI-1 Eligibles are: Those receiving regular full scope Medi-Cal through cash aid, SSI or as MNOs. Those who do not want regular Medi-Cal or who are over the Medi-Cal resource level. QI-1 Aid code is 8D and can be retroactive for 3 months. ISAWS does not support the QI-1 Program. The caseworker must screen for the QI-1 Program manually if the individual fails for SLMB. ***Use the same override procedure as listed above for the SLMB override H:\Analyst\Medi-Cal\MC - Medicare, Buy-In, QMB, SLMB...