Medi-Cal Handbook Medicare Coverage 30. Medicare Coverage · Medicare Coverage 30. Medicare...

Medi-Cal Handbook page 30-1Medicare Coverage

30. Medicare Coverage

30.1 Medicare - Part A & Part B

30.1.1 Overview

Medicare is a federal health insurance program administered by the Social Security Administration. It provides health insurance benefits to eligible persons age 65 or over, and to blind and disabled persons who have been entitled to Social Security disability (RSDI) or Railroad Retirement disability benefits for at least 24 consecutive months. A person in need of renal dialysis or a kidney transplant may also qualify for Medicare. Medicare coverage is composed of two parts, Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).

30.1.2 Covered Services

Part A

Medicare Part A (Hospital Coverage) covers:

• Inpatient hospital care• Inpatient care in a skilled nursing facility for a limited number of days • Hospice Services.

Note:Part A, hospital insurance does not cover physician's services, even when they are received in a hospital.

Part B

Medicare Part B (Medical Insurance) includes, but is not limited to:

• Physician services• Outpatient hospital services• Diagnostic tests• Physical therapy• Limited chiropractic services• Durable medical equipment• Home health services.

Update # 2017-01 Revised: 01/09/2017

page 30-2 Medi-Cal HandbookMedicare Coverage

30.1.3 Persons Eligible

Part A

Persons eligible for Medicare Part A include:

• An individual age 65 or older who is eligible for monthly Social Security benefits (RSDI) or a Railroad Retirement annuity.

• A person age 65 or older and ineligible for RSDI or Railroad Retirement benefits is eligible for Medicare Part A if he/she is all of the following:

• A U.S. Resident, and

• A U.S. Citizen; or, a noncitizen lawfully admitted for permanent residence with 5 years continuous residence.

• Deemed insured, as determined by the Social Security Administration.

Note:The deemed insured provision applies only to women who attained age 65 prior to 1974 (born 1909 or earlier), and to men who attained age 65 before 1975 (born 1910 or earlier).

• A person under age 65 eligible for disability based RSDI or Railroad Retirement benefits, and who has received such benefits for at least 24 consecutive months.

• A person, any age, with end-stage renal disease requiring either a kidney transplant or dialysis. The individual must be one of the following:

• Currently receiving RSDI, or• Railroad Retirement benefits, or• Fully or currently insured, or• The spouse or dependent child of an insured person.

Part B

Persons eligible for Medicare Part B include:

• Any person eligible for Medicare Part A, or

• A person 65 years and older who is:

Revised: 01/09/2017 Update # 2017-01


• A U.S. Resident, and• A U.S. Citizen; or, a noncitizen lawfully admitted for permanent residence

with 5 years continuous residence.

Any person who qualifies for free Part A (Hospital Insurance) is automatically eligible to enroll for Part B (Medical Insurance). For these persons, there are no citizenship status, immigration or U.S. residency requirements.

30.1.4 Premiums

Part A

Part A Hospital Insurance is available to eligible persons at no cost. Approximately 90% of Medicare Part A eligible persons receive the coverage at no cost.

A person who does not qualify for “free” Part A can purchase Part A coverage through payment of a monthly premium if he/she meets all of the following conditions:

• Age 65 and older, and

• A U.S. Resident, and

• A U.S. Citizen; or a noncitizen lawfully admitted for permanent residence with 5 years continuous residence, and

• Enrolled in Part B. Individuals who purchases Part A must purchase Part B.

Note:A person does not have to be retired to get Medicare.

Medi-Cal pays the Part A premium for those persons eligible for the Qualified Medicare Beneficiaries (QMB) Program or the Qualified Disabled Working Individual (QDWI) Program, if they do not already qualify for “free” Part A.

Part B

There is a premium cost for all persons eligible for Medicare Part B.

• The premium cost is deducted from the gross benefit amount of those enrolled persons receiving Social Security or Railroad Retirement payments.

• Other eligible persons can purchase Part B coverage through payment of a monthly premium.

Update # 2017-01 Revised: 01/09/2017


Medi-Cal, through the State Buy-In agreement, pays the Part B premiums of all Medicare recipients, when their Medicare number is correctly transmitted to MEDS. The Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) programs are also available to pay for all or some of the Part B premium. [Refer to “Medicare Buy-In,” page 30-14 for complete Buy-In information.]

30.2 How Medicare And Medi-Cal Work Together

30.2.1 Crossover Claims

Persons who have both Medicare and Medi-Cal are described as having “crossover” benefits. In order to be paid by both Medicare and Medi-Cal, the provider must agree to accept Medicare's allowable charge as payment in full. After the annual Medicare deductible has been met, Medicare will pay the remaining reasonable charges for all Medicare Part A covered services and 80% of the reasonable costs of Part B covered services.

Medi-Cal may or may not pay the remaining charges, or a portion of the remaining charges, depending on the Schedule of Maximum Allowances (SMA) fee schedule.

Medicare is the first to pay for any service that is covered by both programs.

If the provider accepts Medi-Cal for a service, he or she may not bill the patient for more than the amount paid by Medicare plus Medi-Cal.

A Medi-Cal patient, who sees a physician or provider who chooses not to accept Medi-Cal, should be advised by that provider, before services are rendered, that:

• He/she is not being accepted as a Medi-Cal patient, or that the provider may not wish to bill Medi-Cal for a particular service.

• The patient will have to pay the additional amount not covered by Medicare.

Revised: 01/09/2017 Update # 2017-01


30.2.2 Medicare Deductibles

Both Medicare Part A and Part B have deductibles which are paid by the patient or Medi-Cal.

• For the Medi-Cal beneficiaries with no share of cost, or a Qualified Medicare Beneficiary (QMB), these deductibles are paid by Medi-Cal.

• A Medi-Cal beneficiary who is responsible for paying the Medicare deductible can have this expense included in meeting the Medi-Cal share of cost, just as other medical expenses do.

30.2.3 Other Services

Medi-Cal pays the cost of some services which are not covered by Medicare (e.g., certain outpatient prescriptions, custodial level nursing care, glasses, some dental services, hearing aids, etc.).

30.3 The Medicare Card

30.3.1 Description

The Medicare card, (the red, white and blue health insurance card) includes the following information:

• Name and sex of the beneficiary.• Health insurance claim number (HIC).• Date of the beneficiary's entitlement to Medicare Part A and/or Part B.

30.3.2 Medicare Claim Number

The Medicare claim number is also referred to as a HIC number (for Health Insurance Claim number, Social Security claim number, or Railroad Retirement claim number).

The Medicare claim number must be alpha/numeric and has 10 to 12 positions.

A Medicare claim number may be in one of two forms:

Update # 2017-01 Revised: 01/09/2017


1. A Social Security number (9 digits) followed by a suffix (alpha or alpha numeric).

The following codes are frequently seen in HIC numbers:

M = Medicare Only (No SSA benefits)

A = Primary claimant

B = Wife

D = Widow

Example:If an individual has her own Social Security account number and receives Medicare benefit under a spouse's account, the assigned HIC number will be the spouse's Social Security number, followed by a suffix letter B (if living) or suffix letter D (if widowed).

2. A Railroad Retirement number (6 - 9 digits) preceded by a one- to three-letter prefix; for example, WA 693546543.

Note:These letter/number combinations are known as “Beneficiary Identification Codes” (BIC). They identify the account under which the Medicare beneficiary is receiving benefits.

Important:

Some individuals receiving RSDI (retirement, disability or survivor's benefits) have a claim number but are not entitled to Medicare. Such numbers may eventually become the person's Medicare claim number.

30.3.3 Issuance

The Social Security Administration or the Railroad Retirement Board is responsible for issuing the Medicare card to eligible persons.

• A new Medicare card is issued whenever a beneficiary's name, claim number, or dates of entitlement change.

• Beneficiaries who need to have their Medicare cards corrected or replaced should contact Social Security.

Revised: 01/09/2017 Update # 2017-01


30.4 Persons Required to Apply for Medicare [50777]

30.4.1 General

Certain Medi-Cal applicants and beneficiaries are required to apply for Medicare. This requirement applies to U.S. citizens, persons lawfully admitted for permanent residence, undocumented non-citizens and temporary visitors. Some of these non-citizens may not be currently eligible for Medicare; however, they must still apply for it.

30.4.2 Undocumented Non-Citizen

An undocumented non-citizen or temporary visitor who meets any of the criteria in Section 16.4.3 must be referred to Social Security Administration (SSA) to apply for Medicare. These individuals could qualify for free Part A if they have paid into SSA the required quarters or are eligible to receive benefits from a spouse/parent (alive or deceased) who paid into SSA for the required quarters. Per SSA, any person who qualifies for free Part A is automatically eligible for Part B. For such persons, citizenship/immigration status and the length of U.S. residence are immaterial.

Note:An undocumented non-citizen or temporary visitor is not eligible for the Medicare buy-in; however, they must still apply for Medicare. Refer to BENDS #2005-27 to continue to allow Medicare premium deductions indefinitely for these individuals who incur such expenses.

30.4.3 Application Requirements

Part A

The following applicants/beneficiaries are required to apply for Medicare Part A:

• Any person (including undocumented non-citizens and temporary visitors) 64 years and 9 months of age or older.

Note:A CEWA (County Eligibility Worker Alert) will be generated at MEDS Renewal when a beneficiary reaches this age.

Update # 2017-01 Revised: 01/09/2017


• Any person applying for Medi-Cal on the basis of blindness or disability (e.g., SP-DDSD approvals).

• Any person receiving Social Security or Railroad Retirement (RR) disability payments.

Exception:Persons who have received Social Security disability (RSDI) or RR disability benefits for less than 24 months are not eligible for Medicare Part A and are not required to apply for it. These persons will automatically become eligible for Medicare in the 25th month of receipt.

• Any person receiving dialysis-related health care services.

• Any person who has paid into SSA for the required quarters.

• Any person eligible to receive benefits from a spouse/parent (alive or deceased) who paid into SSA for the required quarters.

• Any person applying for Medi-Cal as a “Qualified Medicare Beneficiary” must apply for “Conditional” Medicare Part A if they don't already have it. [Refer to “Qualified Medicare Beneficiary (QMB) Program,” page 30-25.]

30.4.4 Acceptance

“Insured” persons receive Part A (hospital insurance) without paying monthly premiums. However, those “uninsured” persons who would only be eligible for Medicare Part A if they paid a premium are not required to accept Part A benefits.

Part B

The following applicants/beneficiaries are required to apply for Medicare Part B:

• Persons who are applying for Medi-Cal on the basis of being aged.• Persons who are applying for Medi-Cal on the basis of blindness or disability.Exception:

Persons who have received Social Security disability (RSDI) or RR disability benefits for less than 24 months are not eligible for Medicare Part B and are not required to apply for it. These persons will automatically become eligible for Medicare in the 25th month of receipt.

Revised: 01/09/2017 Update # 2017-01


When verification of the beginning month of receipt of RSDI or RR disability is obtained, the EW must set up a case alert indicating the 25th month to begin the Part B Buy-In process.

• Persons receiving dialysis-related health care services.

30.4.5 CalWIN

For those individuals who must apply for Medicare, the Collect Individual Benefit Detail window must be completed to indicate in CalWIN that the client has applied or was referred to SSA; otherwise, the individual will fail in CalWIN. Do NOT complete the Collect Medicare Expense Detail window unless the client is actually receiving, or conditionally eligible for Medicare Part A and/or Part B. Refer to CA 174 for further information.

30.5 Verifying Application for Medicare [50777]

30.5.1 SC 169

The EW may use the “Referral to/from Social Security” (SC 169) to verify application for Medicare.

• The EW must clearly note the purpose of the referral by checking box III, “Application for Medicare.”

• Social Security Administration will respond on the SC 169 with Medicare eligibility information, including determination for non-citizens in the U.S. less than 5 years. The EW must check box IV, “Other Information Requested” and note the following when applicable: “Individual in U.S. less than 5 years. Date of U.S. Entry is ______.

30.5.2 CalWIN Client Correspondence

CalWIN correspondence # SPLTR 744 “Requirement to Apply for Medicare” may be used to:

Update # 2017-01 Revised: 01/09/2017


• Inform the applicant/beneficiary of the requirement to apply for Medicare benefits.

• Verify application for Medicare.

30.5.3 Timeframes

Verification of Medicare approval or denial must be submitted within 60 days of the date that the EW notifies the applicant/beneficiary of the requirement to apply. When application has been made, but eligibility for Medicare has not been determined within 60 days, the EW must:

• Verify that the client has actually applied for Medicare.• Advise the customer that verification must be submitted within 10 days of the

date the customer receives notification of Medicare eligibility or ineligibility.

30.5.4 Client Refusal

If the applicant/beneficiary refuses to apply for Medicare or refuses to provide verification of application, Medi-Cal benefits must be denied or discontinued.

30.5.5 Disenrollment

A beneficiary who is eligible for Medicare must not dis-enroll from Medicare once Medi-Cal eligibility is established.

Should this occur, Medi-Cal benefits must be denied or discontinued. Medi-Cal eligibility must not be restored until verification of reapplication for Medicare is submitted.

30.5.6 Verifications

Medicare eligibility must be verified by viewing any of the following:

• A Medicare card.

• A Social Security award letter showing the beneficiary's Health Insurance Claim number (HIC).

• An explanation of Medicare benefits form (BEOMB), issued by Medicare, showing Medicare payment for a medical bill.

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• A bill for Medicare Part A or Part B.

• Other correspondence from the Social Security Administration which verifies Medicare eligibility.

30.6 Enrollment Periods

30.6.1 Introduction

The following information is a discussion of Social Security Administration's enrollment periods. This information does not change the Medi-Cal requirements for certain persons to apply for Medicare [Refer to “Persons Required to Apply for Medicare [50777],” page 30-7]. In general, there are two periods of time during which a person may enroll in Medicare. An individual can enroll in Medicare during his/her initial enrollment period (IEP), or during the general enrollment period (GEP).

30.6.2 Initial Enrollment Period

The initial enrollment period (IEP) is the period of time when an individual can first apply for Medicare. There are different IEPs for different categories of people. The following is a list of the IEPs for persons age 65, aged noncitizens who meet their 5 years U.S. residency, and other persons who are Medi-Cal eligible. Persons in other special situations who have Medicare questions should be referred to Social Security Administration. EWs are encouraged to advise their customers to apply for Medicare benefits during their IEP.

Persons Age 65

A seven-month period: 3 months before turning age 65; the month turning age 65; 3 months after turning age 65.

Aged Noncitizens Who Meet Their 5 Years U.S. Residency

A seven-month period: 3 months before the month of their 5th anniversary (of continuous U.S. residency); the month of their 5th anniversary (of continuous U.S. residency); 3 months after the month of their 5th anniversary (of continuous U.S. residency).

Update # 2017-01 Revised: 01/09/2017


Persons Eligible for Medi-Cal (ABD-MN/SSI/CALWORKS)

For Medi-Cal recipients who are aged, or who are aged noncitizens, the IEP for Medicare Part A is the same seven-month period as defined above.

For all Medi-Cal recipients, the IEP for Medicare Part B is not limited to any defined enrollment period, due to the State Part B Buy-In agreement. The enrollment period for Part B is when an individual becomes Medi-Cal eligible and Buy-In takes place.

30.6.3 General Enrollment Period

The general enrollment period (GEP) is the period of time from January through March of each year.

• Social Security's term is GEP for this period of time. Staff and the general public also refer to this period of time as the “open enrollment period”.

• Persons who do not enroll for Medicare benefits during their IEP can sign up during this general enrollment period. Medicare benefits are effective in July of the same year.

• Occasionally the Social Security Administration will extend the GEP.

30.7 Medicare Coding

The Medi-Cal record of an individual has Medicare eligibility coding which produce Medicare status codes on the INQM [Medi-Cal/CMSP Information] screen on MEDS. These codes:

• Identify Medicare Part A and/or Part B coverage for eligible Medi-Cal recipients.• Produce a Medicare eligibility message on the providers POS device indicating

that Medicare must be billed prior to billing Medi-Cal.

Note:EWs can view the message on the MEDS Online POS Inquiry (MOPI) screen.

Revised: 01/09/2017 Update # 2017-01


30.8 Medi-Cal Beneficiaries with Medicare and Supplemental Insurance Coverage (OHC)

30.8.1 Option

Medi-Cal recipients who have Medicare and supplemental (Medigap) insurance policies (OHC) have the option of suspending their Medicare supplemental insurance coverage premiums for up to 24 consecutive months while they are Medi-Cal eligible.

Medi-Cal recipients who are interested in suspending their Medicare supplemental insurance policies must contact the private insurance company.

30.8.2 Client and EW Action

Once the Medigap premiums are suspended, Medi-Cal recipients with Medicare must immediately contact their eligibility worker.

The EW must take the following action when they are contacted:

Step Action

1. Update the OHC information and delete the health insurance premium in CalWIN.

2. Send a required ten-day notice if this change results in a share of cost (SOC) and/or an increased SOC.

Update # 2017-01 Revised: 01/09/2017


30.9 Medicare Buy-In

30.9.1 Definition Of Buy-In [50777]

Part A

Effective January 1, 1990, the State will pay (Buy-In) the Medicare Part A (hospital insurance) premium for Qualified Medicare Beneficiaries (QMBs), for those who qualify for it only by paying a premium. However, over 90% of Medicare eligible persons receive Part A at no cost, as they have the required number of work quarters. [Refer to “Qualified Medicare Beneficiary (QMB) Program,” page 30-25 for QMB eligibility requirements.]

Part B

“Buy-In” refers to the arrangement through which the State Department of Health Care Services (DHCS) uses Medi-Cal funds to pay the monthly premiums of Medicare Part B (supplementary medical insurance) for qualifying Medi-Cal beneficiaries, including certain SSI/SSP recipients and ABD-MN individuals. This process ensures that Medicare shares a major portion of the beneficiary's medical expenses. By paying Medicare Part B premiums, DHCS obtains the maximum amount of federal money for the health care costs incurred by Medicare/Medi-Cal beneficiaries. Buy-In is extremely important in reducing the State's total Medi-Cal costs.

30.9.2 Persons Eligible for “Buy-In”

Any person eligible for Medi-Cal with a SOC of $500 or less, or who have met his/her SOC or eligible for QMB/SLMB/QI-1, and eligible for Medicare Part B is entitled to State Buy-In. Persons who are eligible for Buy-In include:

• An individual age 65 or older who is entitled to RSDI or Railroad Retirement benefits.

• Any individual 65 or older who is ineligible for RSDI or Railroad Retirement benefits, when all of the following conditions are met:

• A U.S. resident, and

Revised: 01/09/2017 Update # 2017-01


• A U.S. citizen; or, a noncitizen lawfully admitted for permanent residence with 5 years continuous residence, and

• Deemed Medicare insured, as determined by SSA.

• A person under age 65 receiving Social Security disability or Railroad Retirement disability benefits for at least 24 consecutive months.

• A person, any age, with end-stage renal disease requiring either a kidney transplant or dialysis, providing that the person is one of the following:

• Currently receiving RSDI or Railroad Retirement benefits, or• Currently insured, or• The spouse or child of an insured person.

30.9.3 Persons Ineligible for “Buy-In”

Undocumented noncitizens (in Aid Code 58 and 55) and medically indigent adults/children (in Aid Code 86, 87, 82, 83 and 53) are not eligible for a Medicare Buy-In.

30.9.4 Individuals With SOC

As a result of the 2010/2011 budget trailer bill, SB 853, the Department of Health Care Services (DHCS) stopped paying Medicare Part B premiums for Medicare eligible Medi-Cal beneficiaries who have a Share-of-Cost (SOC) unless the SOC is met on a monthly basis effective April 1, 2011.

Individuals who have SOC will be eligible for the Part B buy in after the full SOC is met or certified.

Individuals who are ineligible for the state buy in of Part B premium may choose to continue receiving their Part B coverage by paying the monthly premium. Those who are receiving Social Security benefits will have their Part B premium deducted from their monthly checks.

Voluntary Disenrollment

Individuals with a SOC who want to voluntarily disenroll from Medicare Part B must contact the Social Security Administration to disenroll. Once disenrolled, the Medicare Part B premium must no longer be allowed as an income deduction.

Update # 2017-01 Revised: 01/09/2017


Note:Disenrollment from Medicare Part B affects eligibility for Medicare Part D prescription drug coverage. Those who disenroll will end up paying for drug prescriptions since Medi-Cal no longer covers prescription drugs for dually Medi-Cal and Medicare eligibles (including those individuals who voluntarily disenroll).

Medicare Part B Enrollment Requirement

Individuals with a SOC are no longer required to apply for Medicare Part B as a condition of Medi-Cal eligibility, unless the individual is also MSP eligible. This is due to the fact that regulations only require individuals to apply for other health coverage (including Medicare) when there is no cost involved to obtain it.

Income Deduction

Individuals who are ineligible or were dropped from buy in AND continued to keep their Part B coverage by paying the monthly premium must be allowed the Part B premium as an income deduction in their Medi-Cal budget to determine the SOC.

If allowing the Part B premium as an income deduction makes them eligible for the Aged and Disabled Federal Poverty Level (A&D FPL) program, the state will pay their premium for the month impacted retroactively. The client will be reimbursed for that month through their SSA benefit retroactively. When this happens, the client is caught in a “revolving door.”

Example:In March 2011, an aged client had a SOC of $90.00. The state stopped the buy in effective 4/1/11. The client received his reduced SSA check on 5/1/11. The client called the EW to report the change and provided verification of his SSA check showing a reduction due to Part B premium payment. The EW must revise the May Medi-Cal budget allowing the $96.40, Part B premium as an income deduction. After the deduction, the client is eligible for A&D FPL program which qualifies him for state buy in. Since the client is now eligible for zero SOC Medi-Cal, the state will start initiating buy in again and the “revolving door” continues.

Retroactive Reimbursement

Retroactive reimbursements are considered property in the month of receipt.

Revised: 01/09/2017 Update # 2017-01


Budgeting

ONLY for individuals who have a SOC and are ineligible for QMB/SLMB/QI-1 do the following policies apply:

• There is no requirement to check Part B buy in either on MEDS or with clients on a monthly basis.

• The EW must not anticipate or predict that Part B buy in will be in effect. This includes individuals who are caught in the “revolving door.” Note: Whenever there is a “revolving door” impact on the client’s SOC, it is to the client’s advantage to continue to allow the Part B premium deduction in the budget as the end result will be the same, which is eligibility for buy in.

If the client is not receiving the full SSA amount as shown on the Income and Eligibility Verification System (IEVS), the EW must not automatically assume that the client is paying Part B premium. Other deductions may possibly include Part C/D premiums, child support or overpayments. It is important that EWs carefully review the information on IEVS, verification provided by the client and/or confirm with the client to determine the types of deductions being taken from the client’s SSA check.

Intake

For new applications, the intake EW must no longer assume that Part B buy in will take effect within two months from the date of approval for individuals with a SOC who are ineligible for QMB/SLMB/QI-1.

Continuing

As the EW becomes aware (e.g., client reported) that the client was dropped off from the Part B buy in due to the state’s non payment of premium, the EW must revise the budget retroactively beginning the month the client’s SSA check is reduced.

30.9.5 Buy-In Procedures - Budgeting

Initiating Buy-In

To ensure statewide uniformity in establishing Buy-In and to eliminate related QC errors, the EW shall initiate the Buy-In process.

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• The EW initiates Buy-In by entering the client's medicare information (including the Health Insurance Claim number [HIC]) in the Collect Individual Benefit Detail and Collect Medicare Expense Detail windows. Entering only the Medicare Premium does not initiate Buy-In.

• Timeliness and accuracy in reporting the HIC number is essential, as late or erroneous reporting results in increased problems, customer complaints, and a possible loss of benefits.

• It is crucial that Buy-In be accomplished quickly to avoid potential hardship. Customers who receive no RSDI or RR benefits must otherwise pay the cost of their Medicare Part B premiums to Social Security Administration.

Buy-In Effective Date

State Buy-In is assumed to be effective in the second month (two months) after the month of approval for MN persons who were not receiving SSI/SSP the month prior to their first month of MN eligibility, regardless of individual cases to the contrary.

The EW shall assume there is no break in Buy-In coverage when the beneficiary has had no break in Medi-Cal eligibility.

The EW shall assume Buy-In and budget the gross RSDI amount in the following cases:

• When a beneficiary changes Medi-Cal status from SSI/SSP to ABD-MN, unless there has been a discontinuance of Medi-Cal benefits for one month or more.

• When changing aid codes within the MN category (i.e., 66-0 to 16-0).

• When the individual changes county of residence (inter-county transfer).

EXAMPLE #1:The applicant signs the SAWS 1 and is approved for eligibility within the same month.

If the customer signs the SAWS 1 in September and eligibility is authorized in CalWIN in September, Buy-In is anticipated in November. CalWIN will no longer allow the medicare premium in the December budget.

EXAMPLE #2:The date of approval is not within the first month of eligibility.

An applicant, over age 65 and currently eligible for Medicare, applies for Medi-Cal in July and is not approved/authorized in CalWIN until September (with begin effective date of July). Buy-In shall be anticipated in November. CalWIN will no longer allow the medicare premium in the December budget.

Revised: 01/09/2017 Update # 2017-01


Premium Reimbursement

The beneficiary will receive a retroactive check for the Medicare premiums which he/she paid in the months covered by the Buy-In agreement.

Note:These SSA reimbursements for the Medicare premium are exempt as a lump sum Title II payment.

Verification

Buy-In must be verified (e.g., MEDS [INQB] screen, IEVS, etc.).

SOC Adjustment

The beneficiary is entitled to a share of cost adjustment when Buy-In has been anticipated, yet did not occur.

Note:[Refer to “Change in the Share of Cost (SOC),” page 62-3, for EW procedures on changes reported timely, or untimely, etc.]

30.10MEDS [INQB] Screen

The INQB [Buy-In and Bendex Information] screen is available through the MEDS system to help EWs determine the Buy-In status of Medi-Cal recipients. This screen also contains Social Security (Title II) eligibility and payment information reported via Bendex.

The code in the [CUR-BUY-IN-STATUS] field on the [INQB] MEDS screen indicates the Buy-In status: accretion pending (i.e. 61), accretion accepted (i.e. 1161), accretion rejected (i.e. 2100). [Refer to User’s Guide to State Systems Handbook, “BUY-IN-ELIG-CD,” page 12-17 for a complete description of Buy-In Status codes.]

Update # 2017-01 Revised: 01/09/2017


30.11 Buy-In Alerts/Messages

30.11.1 Requirements

The EW is responsible for correcting Buy-In and/or Medicare coding problems. Medicare Buy-In alert messages are sent to the EWs advising of any potential Buy-In problems. Messages are generated only for currently active recipients.

Upon receipt of a Buy-In alert, EWs must review the Buy-In information on the INQB screen. [Refer to User’s Guide to State Systems Handbook, “County Eligibility Worker Alerts: 0001-1999,” page 8-1; “County Eligibility Worker Alerts: 2000 - 3999,” page 9-1; “County Eligibility Worker Alerts: 4000 - 8999,” page 10-1; “County Eligibility Worker Alerts: 9000 - 9999,” page 11-1; and “County Eligibility Worker Alerts,” page 7-1; for specific instructions in how to correct an alert.]

30.12Use of the DHCS 6166

30.12.1 When to Use

Buy-In processes are accomplished through the automated data exchange between MEDS and the Social Security Administration. When Buy-In problems occur, EWs must use the on-line systems to resolve them. The form “State Medicare Buy-In Problem Report” (DHCS 6166) is used only after on-line efforts are unsuccessful and the problem requires special handling.

Important:

EWs must first use the MEDS online (SCD 1296) process to correct Medicare coding and Buy-In problems. The DHCS 6166 is used only after efforts by the EW to correct the problem are unsuccessful. EW supervisors must review the problem and the EW efforts to correct it, before a DHCS 6166 is sent.

Revised: 01/09/2017 Update # 2017-01


30.12.2 Situations Requiring the Use of the DHCS 6166

The DHCS 6166 shall be used by the EW to report specific Buy-In problems including, but not limited to, the following situations:

• When an individual is inadvertently dropped (deleted) from Medicare Buy-In.

• To advise DHCS a recipient is entitled to Buy-In when activity (accretion) has not been confirmed after 2 months.

• To change the HIC number on the Medi-Cal record if pending or active (accreted) status is shown on the MEDS INQB screen.

• To remove or modify the Medicare Indicator Code on the Medi-Cal record. (Submit a DHCS 6166 only after corrections through MEDS on-line fail.)

30.12.3 EW Action

Before submitting a DHCS 6166 to the Buy-In Unit, EWs must first:

• Review the Buy-In information on the INQB screen. • Evaluate the [CUR-BUY-IN-STATUS] fields, and• Evaluate the last Part B change date [LAST-PART-B-CHG] and Part A

change date [LAST-PART-A-CHG].

• Review the Medicare status information on the INQM screen.

• Make corrections through the CalWIN/MEDS on-line processes. [Refer to User’s Guide to State Systems Handbook, “County Eligibility Worker Alerts: 2000 - 3999,” page 9-1; “County Eligibility Worker Alerts: 4000 - 8999,” page 10-1; and “County Eligibility Worker Alerts: 9000 - 9999,” page 11-1 for specific instructions in how to correct Buy-In problems.]

• Obtain EW Supervisor approval to send a DHCS 6166 if repeated online attempts to correct the problem have failed.

Update # 2017-01 Revised: 01/09/2017


30.12.4 Completing the DHCS 6166

For the Buy-In Program Unit to successfully resolve a problem case, adequate details are needed on the DHCS 6166. The following information must be included:

• Date of request.• Beneficiary's full name.• Social Security and HIC number.• Date of Birth and Sex.• Medi-Cal effective dates for each period relevant to the problem.• EW's name, address, and telephone.• A detailed description of the problem and the change being requested.

30.12.5 Contacting Medicare Buy In Unit

The EW may contact DHCS to report Buy-In problems either by:

• Completing the State Buy-In Problem Report online on the TPL web page: http://www.dhcs.ca.gov/services/Pages/TPLRD_MOU_cont.aspx

• Completing the DHCS 6166 in the DEBS Forms Library and sending it by Secure e-mail to [email protected].

• Faxing the DHCS 6166 to (916) 440-5677.

• Mailing the DHCS 6166 to:Department of Health Care ServicesMedicare Operations UnitP.O. Box 997422, MS 4719Sacramento, CA 95899-7422

30.12.6 EW Follow-Up

After sending a DHCS 6166 notifying DHCS to resume Buy-In, the EW shall:

• Adjust any overstated share of cost for those months where the customer has met their reporting responsibilities in a timely manner. [Refer to “Share of Cost,” page 62-1 for information on adjusting share of cost.]

• Anticipate completion of the Buy-In process to occur in the second month after the DHCS 6166 notification has been sent to DHCS.

• Monitor the [INQM] and [INQB] screens to ensure that Buy-In occurs.

Revised: 01/09/2017 Update # 2017-01

Medi-C page 30-23Medicare Coverage

Revised: 01/09/2017

30.13M

Me

Pro me Limit

Property Reserve Limit

Effective Date of buy-in

AB(ReMe

e of Cost d on tenance , unless in rogram

1 = $6600

2 = $9910

Part B:

3rd month after approval

SS us levels nding on mstances

1 = $6600

2 = $9910

Part B:

Month approved (cash)

QM of ral rty Level

1 = $6600

2 = $9910

Parts A & B:

Month after approval if on Part A; or July 1 when Part A usually starts

al Handbook

Update # 2017-01

edi-Cal Buy-In Chart

di-Cal Buy-In Chart

What Medi-Cal Pays

Medicare Part A (Hospital Ins.)

Medicare Part B (Doctor’s Medical Ins.)

gram

Scope of Medi-Cal Benefits Prem. Deduct. Co-Ins. Prem. Deduct Co-Ins Inco

D-MN gular di-Cal)

Full X

(If enrolled in Part A)

X


X X X Sharbasemainneeda% p

I/SSP Full X


X


X X X Variodepecircu

B Limited X X X X X X 100%FedePove

Revised: 01/0

page 30- Medi-Cal HandbookMedicare

SL of ral rty Level

1 = $6600

2 = $9910

Part B:

Month of Approval

QI- of ral rty Level

1 = $6600

2 = $9910

Part B:

Month of Approval

QD Federal rty Level

1 = $6600

2 = $9910

Part A:

Month Approval

Pro me Limit

Property Reserve Limit

Effective Date of buy-in

9/2017 Update # 2017-01

24 Coverage

MB Limited X 120%FedePove

1 Limited X 135%FedePove

WI Limited X 200%Pove

What Medi-Cal Pays

Medicare Part A (Hospital Ins.)

Medicare Part B (Doctor’s Medical Ins.)

gram

Scope of Medi-Cal Benefits Prem. Deduct. Co-Ins. Prem. Deduct Co-Ins Inco


30.14Medicare Savings Programs

The Centers for Medicare and Medicaid Services (CMS) discovered an inconsistency when federal, state and local agencies were referring to the Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs.

Different agencies refer to these programs by different names, which can cause confusion and frustration for clients when contacting public agencies for information on these programs.

As a result, CMS will refer to QMB, SLMB and QI programs as “Medicare Savings Programs.” This name was selected based on the results of focus groups testing. Please note that this is not officially a new name by statute, but rather the name CMS and possibly the Social Security Administration will be using.

Note:Clients must NOT be required to apply for Medi-Cal if he/she only wants to apply for QMB, SLMB or QI-1. Eligibility for Medi-Cal is not a requirement to qualify or be eligible for MSP.

30.15Qualified Medicare Beneficiary (QMB) Program

30.15.1 Background

The QMB Program is federally mandated by the Medicare Catastrophic Coverage Act (MCCA), Section 301, of 1988.

• It requires states to pay the Medicare premiums, deductibles and coinsurance of low income Qualified Medicare Beneficiaries.

Note:Coinsurance is the amount Medicare charges the patient. It is based on the Medicare approved rate for a medical service.

Update # 2017-01 Revised: 01/09/2017


• In California, the QMB Program began January 1, 1990, as California was granted a federal waiver due to the need for extensive changes in State legislation.

30.15.2 General Eligibility Criteria

To be eligible as a QMB, a person must:

• Be eligible for Medicare Part A, hospital insurance.

• Be within the property limit.

• Have income at or below 100% of the Federal Poverty Level (FPL). [Refer to Chart Book, for current QMB income limits.]

• Be a citizen or a noncitizen who would otherwise be entitled to full-scope benefits if he/she were applying for regular Medi-Cal.

Note:An undocumented noncitizen or an amnesty noncitizen who would only get restricted Medi-Cal benefits is not eligible for QMB.

• Be otherwise eligible for Medi-Cal (for example, meet California residency and verification requirements).

Note:Application or eligibility for Medi-Cal is not required to qualify and be eligible for QMB.

30.15.3 Two Basic Groups of QMBs

There are two basic groups of QMB eligibles; “QMB Only” recipients and “Dual Eligibles”. The description of each group and the benefits received are described in the chart that follows:

Applicant Type Medi-Cal Benefits Advantages

QMB Only

Revised: 01/09/2017 Update # 2017-01


30.15.4 When to Evaluate for QMB

EWs must evaluate QMB eligibility when:

• An applicant is applying for QMB.

• A Medi-Cal applicant is aged, blind or disabled and has Medicare (or is potentially eligible for Part A).

Aged, blind or disabled (ABD) persons who:

Are NOT eligible for full-scope Medi-Cal due to excess property, or

Are eligible for full-scope Medi-Cal but choose to apply for only QMB.

Receive a Medi-Cal BIC.

POS Device message will indicate that Medi-Cal coverage is only for MEDICARE DEDUCTIBLES AND COINSURANCE”.

Covers Medicare:

• Premiums (Part B for all QMBs and Part A for those who do not already get Part A free.)

• Deductibles.

• Coinsurance, based on Medicare approved rate.

Higher property limits.

NOTE: EWs should encourage full-scope Medi-Cal whenever possible, as regular Medi-Cal covers more than QMB, including:

Medicare Part B premium (thru Buy-In), Medicare deductibles and coinsurance.

Additional medical services; including, but not limited, to:

• Outpatient prescriptions and eye glasses.

• Custodial and skilled nursing facility level of care.

Dual Eligible QMBs

Qualify for full Medi-Cal, Medicare Part A, and have income at or below the QMB income limit, including:

• Some ABD-MN persons.

• SSI/SSP recipients with or without “free” Part A.

• Certain IHSS or CalWORKs recipients.

Receive their regular Medi-Cal; however, the QMB aid code is reported to MEDS and can be viewed on one of the Special Program Screens.

POS Device Message: “1st SPECIAL AID CODE: 80 PART A, B MEDICARE COVERAGE W / HIC #_____ BILL MEDICARE COVERED SERVICES TO MEDICARE BEFORE MEDI-CAL.”

• The state receives federal funding for Buy-In.

• Once enrolled in Medicare Part A, individuals have a slightly wider choice of hospitals and nursing homes.

• Medi-Cal pays the Part A premium for those persons who do not receive it free.

Applicant Type Medi-Cal Benefits Advantages

Update # 2017-01 Revised: 01/09/2017


• An SSI/SSP recipient applies for QMB and has Part B Medicare and no Part A; or, pays a premium for Part A.

• An SSI/SSP recipient who already has Part A free.

• An aged, blind or disabled Medicare eligible person is included in a CalWORKs cash household or is applying for IHSS.

• A redetermination is due.

• A person is eligible for Medicare Part A and there is a change in income or a change in the QMB income limits.

30.15.5 Effective Date of Eligibility

There is no retroactive eligibility for QMB.

For those applicants/beneficiaries that already have Medicare Part A, eligibility begins the first of the month following the date that the EW actually determines and authorizes QMB eligibility in CalWIN.

Note:This requirement is due to the State Buy-In agreement with the Social Security Administration.

Example:QMB Only A customer applies for QMB January 15. The EW interviews the customer in February and clears eligibility February 8. The effective date of QMB eligibility is March 1. However, it will take 2-3 months for Buy-In to take place. Once Buy-In is activated, the customer will be reimbursed for the Medicare Part A and/or Part B premium back to March.

Example:Dually Eligible A customer applies for Medi-Cal January 31. The EW determines on 3/2 that there is Medi-Cal eligibility effective January 1 and that the client is under the QMB income limit. QMB eligibility begins April 1.

Revised: 01/09/2017 Update # 2017-01


Example:Approved Month Following the Application The customer applies and is interviewed in March. The EW did not clear eligibility until 4/15. QMB eligibility begins April 1, as the EW cleared eligibility in March.

Pre-Approved QMBs

Persons who meet QMB eligibility criteria, but who must apply for Medicare Part A during the “general enrollment period” (because they did not apply during their “initial enrollment period”), are “pre-approved QMBs”. Their QMB benefits will actually begin July 1.

Ineligible QMBs

Persons applying between April and December who do NOT have Medicare Part A, must be referred to SSA to apply for conditional Part A. If SSA does not allow them to apply for conditional Part A, deny the application.

Note:If they appear to meet the other QMB criteria, advise them to apply for conditional Part A at SSA during the next general enrollment period (January-March), and reapply for QMB.

30.15.6 Verification of Medicare Part A

Medicare Part A benefits must be verified. Verification includes any of the following:

• The Medicare card (“Hospital insurance” indicates Part A coverage).

• An SSA Medicare Award Letter.

• A print of the MEDS [Buy-In Bendex Information] screen showing Part A entitlement.

• Other correspondence from SSA.

• Verification from IEVS (Applicant System).

Update # 2017-01 Revised: 01/09/2017


30.15.7 “Conditional” Medicare Part A

Those individuals who are not receiving Part A but who would be eligible for it by paying a premium may sign up for “conditional” Part A Medicare.

• This means the client is requesting Part A Medicare only if the state pays the premium. They will not be charged a premium if ineligible for QMB.

• Conditional enrollment must take place between January 1 and March 31, or during the individual's initial enrollment period when he/she first becomes entitled to Medicare.

Note:The Social Security Administration sometimes extends the general enrollment period.

Example:Client turns 65 in December 2006. Per SSA verification, client is Part A eligible effective 12/06. The EW must enter a value of N in the Conditional field on the Collect Medicare Expense Detail window.

30.15.8 MC 176 QMB-3

QMB applicants are to be referred to their local Social Security Administration office with a “Qualified Medicare Beneficiary (QMB) Referral” (MC 176 QMB-3) when:

• It is necessary to apply for conditional Medicare Part A, or• They state that they have Medicare Part A or that they think they are eligible for

it, however they do not have any verification.

Note:Social Security uses the “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SC 176 QMB) in the SSI QMB Mail-In Referral procedure. This procedure allows Social Security to refer by mail all SSI/SSP recipients who are “conditionally” eligible for Medicare Part A to Social Services to apply for QMB. [Refer to “SSI QMBs,” page 30-36.]

Revised: 01/09/2017 Update # 2017-01


QMB applications shall be recorded according to the information provided on the MC 176 QMB-3 or other verification from the Social Security Administration as follows:

If... Then...

The QMB applicant is CONDITIONALLY ELIGIBLE for Medicare Part A (is applying for Part A during the general enrollment period)

Approve QMB. Benefits will actually begin July 1.

Follow up immediately to ensure that:

• A MEDS QMB record has been established on the Special Program 1 Information [INQ1] screen, and

• A pending accretion is showing on the Buy-In and Bendex Information [INQB] screen.

Follow up in August to verify Medicare approval and:

• Review the MEDS [INQM] and [INQB] screens to determine if the Buy-In accretion was successful.

• Take corrective action if Buy-In rejection occurs.

The QMB applicant is ELIGIBLE for Medicare Part A

Approve QMB. Eligibility is effective whichever of the following dates is later:

• The Medicare Part A effective date, or • The first of the month following the date the

EW determines QMB eligibility.

The QMB applicant is NOT ELIGIBLE for Medicare Part A or must reapply during the general enrollment period

Deny/discontinue QMB.

30.15.9 QMB Property Determination

The net non-exempt property of a QMB applicant/beneficiary prior to 1/1/2010 cannot exceed twice the Medi-Cal property limit. As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI).

[See Chart Book “Current QMB/SLMB/QI Program Income/Property Limits,” page 5-20]

Update # 2017-01 Revised: 01/09/2017


Note:The QMB property rules contained in this section also apply to the Specified Low-Income Medicare Beneficiary (SLMB) Program and the Qualifying Individual (QI-1) Program.

The “QMB/SLMB Property Worksheet, Adult” (MC 176P QMB/SLMB-A) is used (optional) when determining eligibility for the QMB/SLMB/QI Only programs.

If the QMB applicant/recipient is eligible for Medi-Cal from another program (e.g., ABD-MN, SSI/SSP) the QMB property limit is met.

Rules

The EW must follow the rules below when determining QMB property eligibility for the following groups of people:

Individuals (Adults) with no Spouse (age 18 and over)

First determine property under regular Medi-Cal rules. (MFBU rules apply.) The individual is dually eligible if equal to or under the Medi-Cal property limit.

If over the regular Medi-Cal property limit, then the following apply:

• Count only the resources of the QMB/SLMB/QI applicant.• Do not consider the property of other family members in the home.• The applicant is QMB/SLMB/QI property eligible if equal to or under twice the

Medi-Cal property limit for one.

Persons Ages 18-21

A QMB/SLMB/QI applicant age 18-21 is considered an adult for a QMB (or SLMB) property determination, even though he/she would be treated as a child for regular Medi-Cal (e.g., is a blind or disabled MN person who is living in the home of a parent and is currently in school).

• Determine property under regular Medi-Cal rules if applying for regular Medi-Cal. (MFBU rules apply.)

• For QMB/SLMB/QI, count only the resources of the 18-21 year old and his/her spouse, if any.

Couples, Both Spouses in Home

These rules apply whether one or both spouses are applying for QMB/SLMB/QI.

Revised: 01/09/2017 Update # 2017-01


• A married person under age 18 is considered to be an adult for QMB/SLMB/QI.

• If only one spouse is receiving Medi-Cal from another program, the QMB/SLMB/QI property limit is met for both spouses.

• First determine property limit. (MFBU rules apply.) The individual (or couple) is dually eligible if their property is equal to or under the LIS property limit.

• If over the property limit, then complete STEP II of the property worksheet (MC 176 P).

• Count only the resources of the QMB/SLMB/QI applicant and his/her spouse.

• Do not count the separate resources of minor children or other family members.

• The individual/couple is QMB/SLMB/QI property eligible if their property is equal to or under the property limit for one/two.

Child, Under 18

Rarely will a child under age 18 be eligible for QMB/SLMB/QI, as a child can only be eligible for Medicare if in need of maintenance kidney dialysis or a kidney transplant.

Contact the Medi-Cal Coordinator for instructions. The property determination is different from the instructions outlined above.

30.15.10 Other Requirements

QMB Only applicants/beneficiaries must meet all other Medi-Cal Program requirements, including:

• Completion of all appropriate Medi-Cal forms (MC 210, MC 13, Rights and Responsibilities, etc.)

Note:Although the “QMB/SLMB/QI Application Form” (MC 14 A) was not originally designed as a QMB application, the EW must NOT require an individual who submits a MC 14 A to complete a MC 210 if it is determined that the individual should be evaluated as a QMB rather than as a SLMB or QI.

• Providing any necessary verifications. (IEVS is required.)

• Completing an annual redetermination.

Update # 2017-01 Revised: 01/09/2017


• Reporting any changes within 10 days. (Income reports are not required for ABD-MN households.)

• Maintaining California residency.

30.15.11 Notices of Action

EWs are required to determine the level of benefits each Medi-Cal applicant is entitled to, explain the options (including spenddown), and issue benefits and the appropriate notices of action.

Approvals

A QMB Approval NOA must be issued when:

• A person is eligible for QMB only.

Note:Send the appropriate denial for regular Medi-Cal benefits (e.g., excess property).

• A person is otherwise eligible for QMB and is “Preapproved” pending confirmation of eligibility for Medicare Part A.

• When an ABD-MN eligible person who is paying his/her own Medicare Part A premium is income eligible for QMB, and is therefore entitled to State Buy-In of the Part A premium.

A QMB Approval NOA must NOT be issued when an individual is dually eligible and receives Medicare Part A free.

Note:In this situation the client receives no additional benefits. However, the State will receive federal funding for Buy-In.

Denials/ Discontinuances NOA

Denial and discontinuance NOAs are automatically generated when the QMB budget computation determines that the client is not income eligible for QMB.

A QMB denial or discontinuance must be sent when:

Revised: 01/09/2017 Update # 2017-01


• A person has applied for, or received, QMB Only and is found ineligible. (e.g., excess income, property, not a resident, etc.)

• A “pre-approved” person is found ineligible for Medicare Part A.

• An ABD-MN applicant/recipient person is not eligible (or no longer eligible) for Buy-In of his/her Part A premium payment due to excess income.

A QMB denial or discontinuance NOA is NOT required for dually eligible ABD-MN applicants/recipients who have free Medicare Part A coverage.

Erroneous Discontinuance

The QMB eligibility must be restored back to the date the QMB eligibility was erroneously discontinued. Although the QMB does not provide retroactive eligibility, eligibility can and must be reinstated for past months (there should not be any break in aid) when a client was eligible.

In order for QMB buy-in to be reinstated, the Medi-Cal Buy-In unit must retroactively pay for all Medicare premiums in arrears to Social Security Administration. Once the QMB eligibility is restored on MEDS, the State’s Medicare Buy-In system will process a Medicare Part A buy-in transaction. In order to ensure that the Medi-Care buy-in transaction is processed correctly, the EW can call the Buy-In unit or submit a State Medicare Buy-In Problem Report (DHCS 6166) to DHCS, Medi-Care Buy-In unit.

30.15.12 ICTs

QMB Only

QMB Only cases follow current ICT procedures. [Refer to “Intercounty Transfer (ICT),” page 19-1.]

SSI QMBs

The EW in the old county will receive an alert (CEWA) when the SSI county of responsibility changes. Initiate an ICT to the new county when the MEDS alert is received.

Update # 2017-01 Revised: 01/09/2017


30.15.13 SSI QMBs

General

SSI/SSP recipients have full Medi-Cal coverage. However, they may benefit from Buy-In of their Part A premium if they are QMB eligible and:

• They are paying a premium for their Medicare Part A benefits, or• They don't have Medicare Part A because they cannot afford to pay the

premium.

Medicare Part A benefits may provide them with a slightly wider choice of hospitals; otherwise, there is no benefit.

Application Forms

An SSI/SSP recipient has already been determined eligible for and is receiving Medi-Cal. Therefore, when an SSI/SSP recipient applies for QMB, the only application forms required are an SC 41 and a SAWS 1.

SSI QMB Mail-In Referral Procedure

The following SSI QMB Mail-In Referral procedure has been established with the Santa Clara County Social Security Field Offices.

Stage Who Action

1. Social Security Completes an “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SC 176 QMB) for each SSI recipient applying for “conditional” Medicare Part A.

Mails the SC 176 QMB directly to the Assistance Application Center (AAC) as an application for QMB Medi-Cal.

2. AAC Mail Room Forwards the SC 176 QMB to the Clerical ID Lead.

3. ID Lead Forwards the SC 176 QMB as follows:

IF there is... THEN the SC 176 QMB is sent to...

An active case record in any aid type,

The supervisor of the current case carrying EW.

NO active case record, The appropriate intake office, as determined by census tract.

4. Receiving District Office

Ensures that the SC 41 and SAWS 1 is completed. Ensures that the application is ID’d and assigned timely.

Revised: 01/09/2017 Update # 2017-01


Other Referrals

SSI/SSP recipients who are not referred by Social Security to the county by mail with a SC 176 QMB may apply for QMB by phone or in person.

• Forward QMB phone applications from SSI/SSP recipients to intake for processing (or to the current EW is there is an open case).

• Persons who apply for QMB in person may be issued an MC 14A or MC 210 by the receptionist; however, completion of the MC 14A, MC 210, MC 13 or any other Medi-Cal forms is not required for SSI/SSP QMB applicants.

Application Requirements

• A face-to-face interview is NOT required.

• A property determination is NOT required.

5. EW Determines SSI QMB eligibility.

• Use the [INQX] MEDS screen to verify and determine income eligibility.

• Use the SC 176 QMB as verification of “conditional” Medicare Part A.

The SC 176 QMB and copies of MEDS screens used to verify income and Medicare eligibility must be retained in the case file.

Approves/Denies the QMB application and issue the appropriate approval Notice of Action (NOA).

If approved, completes the appropriate follow-up action.

• Ensures an active QMB record is established on the MEDS Special Program 1 Information [INQ1] screen.

• Ensures Buy-In accretion is initiated (i.e. “61” in the [CUR-BUY-IN-STATUS] field on the [INQB] MEDS screen).

• Ensures Buy-In accretion is later added to the Buy-In Program (i.e. “1161” in the [CUR-BUY-IN-STATUS] field on the [INQB] MEDS screen).

[Refer to User’s Guide to State Systems Handbook, “BUY-IN-ELIG-CD,” page 12-17 for a complete description of the coding found in the [CUR-BUY-IN STATUS] field.]

Stage Who Action

Update # 2017-01 Revised: 01/09/2017


• An income determination is required. [Refer to “Income Determination,” page 30-38.]

• Verification of “conditional” Medicare Part A is required. [Refer to “Verification of Medicare Part A,” page 30-38.]

• An SSI QMB applicant must receive a QMB approval or denial NOA.

Income Determination

EWs must determine the SSI/SSP recipient's net non-exempt income.

SSI/SSP income is exempt.

The [Title XVI-SSI/SSP Information] screen can be used to verify countable income (INQX). File screen print in the case record.

• If the NET-UNEARN-INC, NET-EARNED-INC and DEEMED-INCOME are equal to or less than the QMB income limit for one, the person is QMB eligible.

• If the total countable income is over the QMB income limit for one, the person is ineligible for QMB.

If the information from the [Title XVI-SSI/SSP Information] screen is not available, use other income verifications and complete the MC 176 QMB/SLMB 2A (or use MACB whenever possible).

Verification of Medicare Part A

The SSI/SSP recipient must verify that he/she has applied for “conditional” Medicare Part A.

• The SC 176 QMB is used by Social Security to refer an SSI/SSP recipient to Social Services by mail to apply for QMB. This form serves as verification that the SSI/SSP recipient has applied for “conditional” Medicare Part A.

• The MC 176 QMB-3 is used to refer an SSI/SSP recipient who has filed an application for QMB, but has not yet filed an application for Medicare Part A to the Social Security Administration to apply for “conditional” Medicare Part A. This referral should only be done after QMB income eligibility is determined.

(1) Mail the MC 176 QMB-3 to the recipient, or issue in person, during SSA's “general enrollment period”, January 1 through March 31. (NOTE: Sometimes SSA extends the general enrollment period.)

Revised: 01/09/2017 Update # 2017-01


(2) Deny the QMB application if SSA states that the person is not eligible for Medicare Part A or that he/she must wait until the next “general enrollment period” to apply.

[Refer to “MC 176 QMB-3,” page 30-30 for additional information about processing the MC 176 QMB-3 and the actions to be taken when SSA verifies the status of Medicare Part A.]

The verification of Part A entitlement (SC 176 QMB or MC 176 QMB-3) must be filed in the casefolder.

Redetermination (RDs)

The EW must review MEDS to ensure that the individual is still receiving SSI. Once SSI eligibility is confirmed, only two requirements must be completed by the EW:

1. Reverify the SSI/SSP recipient's net non-exempt income via the [INQX] screen on MEDS. [Refer to “Income Determination,” page 30-38.]

2. Check the [INQ1] and [INQB] MEDS screens to ensure that QMB eligibility is being correctly reported to MEDS and that verification of Medicare Part A entitlement is on file.

Deny or discontinue QMB if the individual is ineligible for Part A.

Copies of MEDS screens used to verify income and Medicare eligibility must be retained in the case file. No other forms or verifications are necessary for SSI QMB redeterminations.

Discrepancies

Occasionally the EW will receive information from an SSI QMB applicant which is inconsistent with SSI and/or QMB eligibility rules. Although the EW is not required to verify anything beyond income (as recorded on MEDS) and Medicare Part A entitlement, discrepancies in reported information must be resolved.

For example, while an SSI recipient is applying for QMB she tells the EW that she has $20,000 in savings. The EW is to deny QMB for excess property, advising the customer of the QMB property limit. Also, advise the customer that she is over the SSI property limit and that she is to report this information to the Social Security Administration. The EW is not required to contact Social Security and need not follow-up to see that the customer has done so.

Update # 2017-01 Revised: 01/09/2017


Whereabouts Unknown Discontinuance

Prior to discontinuing an SSI QMB case due to returned mail, the EW must review the SSI MEDS record or contact the Social Security Administration via a “Referral of Applicant to SSA” (SC 169) to determine if the beneficiary has reported a new address to Social Security. If this information is available, the EW must update the CDS record and reissue the returned mail. The case must not be discontinued due to “Whereabouts Unknown”. If a new address is not available from MEDS and/or Social Security, the case must be discontinued due to “Whereabouts Unknown”.

30.16Specified Low-Income Medicare Beneficiary (SLMB) Program

30.16.1 Background

The Specified Low-Income Medicare Beneficiary (SLMB) Program is federally mandated by Section 4501(b) of OBRA '90, Public Law 101-508. Essentially, SLMB is a QMB with more income. Individuals with income over the QMB income limit (100% of the Federal Poverty Level), but under the SLMB income limit (120% of the Federal Poverty Level), are eligible for payment of their Medicare Part B premium under the SLMB Program.

It is anticipated that very few people will be eligible for this program, as a SLMB recipient must have income greater than 100% of the Federal Poverty Limit (FPL) but less than 120% of the FPL.

Reminder:Application or eligibility for Medi-Cal is not required to qualify and be eligible for SLMB.

30.16.2 Effective Date

The SLMB Program is effective 1/1/93.

Eligibility begins the month of application if all eligibility requirements are met, but not prior to 1/1/93.

Unlike QMB, clients may apply for 3-month retroactive SLMB.

Revised: 01/09/2017 Update # 2017-01


30.16.3 Benefit

Persons who apply for SLMB Only get payment (Buy-in) only for their Medicare Part B premium and no other benefits. SLMB does NOT pay for one's Medicare Part A premium, or for Part A and B deductibles and coinsurance.

SLMB only recipients do NOT receive a Medi-Cal BIC.

• Once State Buy-In of their Medicare Part B premium begins, the premium will not be deducted from their Social Security check. They will have an increase in their monthly net income.

• SLMB eligibility can be viewed on MEDS, Aid Code '8C' on the Special Program screen.

Individuals who qualify for Medicare Part B may apply for it at any time at the Social Security office. That is, if they refused Part B coverage during their “initial enrollment period” they do not have to wait until SSA's “general enrollment period” (January - March) to apply.

30.16.4 Eligibility Criteria

SLMB applicants/recipients must meet all of the following eligibility criteria:

Medicare Part A

Is eligible for Medicare Part A, either free or they pay for it.

Important:

“Conditional” Medicare Part A applications are not allowed in the SLMB Program. SLMB applicants must be eligible for Part A free or pay their own Part A premium in order to be potentially eligible for SLMB. “Conditional” Medicare Part A only applies to the QMB Program.

Property

The property limit is the same as QMB, prior to 1/1/2010, twice the Medi-Cal property limit:

• $4,000 for one person• $6,000 for two persons

Update # 2017-01 Revised: 01/09/2017


As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI). [See Charts Book “Current QMB/SLMB/QI Program Income/Property Limits,” page 5-20

Income

SLMB eligibles must have income in excess of the QMB income limit, but less than the SLMB income limit:

• 110% of the Federal Poverty Limit in 1993 and 1994.• 120% of the Federal Poverty Limit in 1995 and continuing.

Citizen/ Noncitizen Status

SLMB eligibles must be a citizen or a noncitizen who would otherwise be entitled to full-scope benefits if applying for regular Medi-Cal. An undocumented noncitizen who would only get restricted Medi-Cal benefits is not eligible for SLMB.

Other Requirements

SLMB applicants/beneficiaries must meet all other Medi-Cal Program requirements, including:

• Completion of the “Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individuals Application” (MC 14 A).

Note:An individual who completes an MC 210 does not have to complete an MC 14 A to have eligibility determined under the SLMB/QI programs.

Reminder:Application for Medi-Cal is not required to be eligible for QMB.

• Providing any necessary verifications. (IEVS is required.)



Revised: 01/09/2017 Update # 2017-01


30.16.5 Dual Eligibility

If the client is eligible for Medi-Cal and has income below 100% FPL, there is no need to set up SLMB as the buy-in for Part B will be initiated once Medi-Cal eligibility is authorized and the HIC number is entered.

ABD-MN

EWs must identify SLMB eligibility for those persons who qualify for regular Medi-Cal ABD-MN benefits, have Medicare Part A and B, and whose income is over the QMB income limit but below the SLMB income limit.

These “dual eligibles” (ABD-MN and SLMB) will receive their regular plastic Benefits Identification Card (BIC). However, the SLMB aid code will be reported to MEDS so that the state can receive federal funding for their Part B Buy-In.

SSI/SSPs, SLMB Does NOT Apply

PERSONS RECEIVING SSI/SSP ARE NOT SLMB ELIGIBLE. In addition, EWs will NOT identify SLMB eligibility for persons who are receiving IHSS or who are “Pickle” eligible. (The state already receives federal funding for Buy-In for these persons.)

30.16.6 When to Evaluate

EWs are required to determine the level of benefits each Medi-Cal applicant is entitled to, explain the options (including spenddown), establish benefits and the appropriate notices of action.

ABD-MN recipients must be reviewed for SLMB “dual eligibility” at the following times:

• At RD, or• When there is a change in income, or• When there is a change in the SLMB income limit. (The SLMB income limit

changes annually in April due to the Federal Poverty Level (FPL) changes.)

Update # 2017-01 Revised: 01/09/2017


30.16.7 NOAs

SLMB Only

Approval, denial and discontinuance NOAs are required for SLMB Only persons.

ABD-MN and SLMB (Dual Eligibles)

No SLMB NOAs are to be issued to “dual eligibles”.

30.17Qualifying Individual (QI-1) Program

30.17.1 Background

Section 4732 of the Balanced Budget Act of 1997 established the Qualifying Individual (QI-1) program. This program pays the Medicare Part B premium. The QI-1 program is a federally funded program which is similar to the Qualified Medicare Beneficiary (QMB) and the Specified Low-Income Medicare Beneficiary (SLMB) programs but allow for a higher income limit.

Revised: 01/09/2017 Update # 2017-01


30.17.2 Overview

The Qualifying Individual (QI-1) program is similar to the SLMB program except that it allows a higher income limit. The following chart provides an overview of the QI-1 program:

ProgramAid Code

Benefit Provided Income Limit Program Requirements

Qualifying Individual-1 (QI-1)

8D Buy-In of the Medicare Part B premium.

135% of FPLa

a. The Federal Poverty Level is established annually in April.

Income is equal to or more than the SLMB income limit (120% of FPL), but less than 135% of FPL.

1. Eligible for and receiving Medicare Part A. (Conditional Part A does not meet this criteria.)

2. Is within the QI property limit. [Refer to “Property,” page 30-46.]

3. Not “eligible for Medi-Cal”. [Refer to “Dual Eligibility,” page 30-48.]

4. Is a citizen or a noncitizen who would otherwise be entitled to full-scope benefits.

5. Meets the other Medi-Cal eligibility requirements (e.g. residency, etc.)


The QI-1 Program is effective 1/1/98. Eligibility begins the month of application if all eligibility requirements are met, but not prior to 1/1/98.

30.17.4 Retroactive QI-1 Benefits

Individuals may apply for 3-month retroactive QI-1 benefits if they were entitled to Medicare Part A and B in those months and are otherwise eligible. They may not, however, be approved for month(s) prior to 1/1/98.

30.17.5 Benefit

Persons who qualify for QI-1 program are eligible only for payment (Buy-in) of their Medicare Part B premium and no other benefit.

Update # 2017-01 Revised: 01/09/2017


• The QI-1 program pays the full Medicare Part B premium. Once Buy-In of the Part B premium begins, the premium will not be deducted from the recipient’s Social Security check. The customer’s net monthly income will increase.

• The QI-1 program does NOT pay the Medicare Part A premium, nor for Part A and B deductibles and coinsurance.

• If the client is eligible either for regular Medi-Cal, QMB or SLMB, there is no need to set up QI-1 because the buy-in is already taken care of. Reminder: Application or eligibility for Medi-Cal is not required to qualify or be eligible for QI-1.

• QI-1 only recipients do NOT receive a Medi-Cal BIC.

Note:Eligibility for the QI-1 program (Aid Code 8D) can be viewed on MEDS on one of the Special Program screens, [INQ1] or [INQ2].


If the client is eligible either for regular Medi-Cal, QMB or SLMB, there is no need to set up QI-1 because the buy-in is already taken care of. Application or eligibility for Medi-Cal is not required to qualify or be eligible for QI-1. Clients must not be required to apply for Medi-Cal if he/she only wants to apply for QI-1.

In addition, he/she must meet all of the following eligibility criteria:

Medicare Part A

Is eligible for Medicare Part A, either free or he/she pays for it.

Important:

“Conditional” Medicare Part A does not meet this requirement. QI-1 applicants must actually be eligible for and in receipt of Part A in order to be eligible for the QI-1 program.

Property

The property limit is the same as the QMB/SLMB programs, prior to 1/1/2010, twice the Medi-Cal property limit:

Revised: 01/09/2017 Update # 2017-01



As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI). [See Charts Book “Current QMB/SLMB/QI Program Income/Property Limits,” page 5-20]

Resources must be declared on the statement of facts, but the customer is not required to provide verification. EWs must accept the customer’s statement. Verification is only required when the customer’s statement is inconsistent with information received from another source (i.e., IEVS).

The EW must complete the “QMB/SLMB/QI Property Worksheet - Adult” (MC 176 P-A QMB/SLMB/QI) to determine and document property eligibility for the QI-1 program.

Income

QI-1 eligibles must have income at or above the SLMB income limit (120% of the FPL), but less than the QI-1 income limit (135% of FPL).


QI-1 eligibles must be a citizen or a noncitizen who would otherwise be entitled to full-scope benefits if applying for regular Medi-Cal. An undocumented noncitizen who would only get restricted Medi-Cal benefits is not eligible for QI-1.

Other Requirements

QI-1 applicants/beneficiaries must meet all other Medi-Cal Program requirements, including:

• Completion of the “Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individuals Application” (MC 14 A).

Note:An individual who has already completed an MC 210 does not have to complete an MC 14 A to have eligibility determined under the SLMB/QI programs.

• There is no face to face requirement if the customer is applying for QI-1 Only.

Update # 2017-01 Revised: 01/09/2017


• Providing verification of income.

• Completing an annual redetermination. (Face-to-face redetermination interviews are not required for QI-1 cases.)



30.17.7 When to Evaluate

QI-1 eligibility must be reevaluated whenever there is:

• An annual redetermination due, or• A change in income, or• A change in the QI-1 income limits, or• A person becomes ineligible for QMB and SLMB.

Note:The QI-1 income limits change annually in April when the annual Federal Poverty Level (FPL) is established. The EW must disregard the Social Security Cost of Living Adjustment (COLA) between January 1 and March 31 of each year.

30.17.8 NOAs

Approval, denial and discontinuance NOAs are required for QI-1 applicants/recipients. Ten-day notice requirements apply.

30.17.9 Dual Eligibility

Rule

EWs must only establish QI-1-only eligibility. There is NO dual eligibility for ABD-MN (zero or share of cost met) and the QI-1 program.

There is dual eligibility (regular Medi-Cal and QI-1) for Medi-Cal recipients who have not met their share of cost.

Revised: 01/09/2017 Update # 2017-01


30.18QMB/SLMB/QI Income Determination and Budgeting Rules

These rules apply to QMB, SLMB and QI-1 beneficiaries, including “dually eligibles”.

30.18.1 Income Rules, General

The following rules apply to QMB, SLMB and QI-1 income determinations:

• QMB, SLMB and QI-1 income eligibility is based on a percentage of the federal poverty level. The individual’s income must be less than the QMB, SLMB or QI-1 income limits.

Important:

The RSDI COLA (which is received in January) cannot be used to compute QMB, SLMB or QI-1 eligibility from January through March if it causes ineligibility. The Federal Poverty Level figures are published annually and are effective on April 1st. By disregarding the COLA increase, clients will not lose their Medicare benefits in the interim.

• Medi-Cal income rules are first used to determine QMB, SLMB, or QI-1) eligibility. If a couple is not eligible using Medi-Cal rules, a second budget is computed using SSI rules, as they may be more advantageous.

• SSI/SSP income is exempt for QMB.

• Do not count other PA income of the QMB/SLMB/QI applicant, spouse or child (e.g., SSI, or CalWORKs).

• Use the regular Medi-Cal income-in-kind rules, when applicable. (Not ISM.)

30.18.2 Budgeting, MC 176-1 QMB/SLMB/QI

To determine the net non-exempt income of a QMB/SLMB/QI applicant or couple:

• Determine all members of the MFBU (eligible and ineligible). Include applicant, spouse, minor children (if any).

Update # 2017-01 Revised: 01/09/2017


• Count gross unearned income.

• Allow the $20 any income disregard.

• Allow the $65 + 1/2 deduction from the gross earned income of the QMB applicant or spouse.

• The actual Impairment Related Work Expenses of a working, disabled QMB applicant/beneficiary are allowed as a deduction from his/her earned income.

• Do not deduct the health insurance premium and other allocations.

If the... Then...

QMB/SLMB/QI applicant is single or in his own MFBU

If income is less than or equal to the QMB limit, he/she is QMB eligible.

If income is less than the SLMB or QI-1 limits, he/she is SLMB for QI-1 eligible.

QMB/SLMB/QI applicant's spouse has no income

The SSI income rules used on the MC 176 QMB/SLMB 2A will not help.

QMB/SLMB/QI applicant has a spouse with income or a spouse with income and minor children

Determine if there is QMB/SLMB/QI eligibility using SSI rules.

30.18.3 Budgeting, MC 176-2A QMB/SLMB/QI

The MC 176-2A QMB/SLMB/QI uses SSI income rules when a couple is over the QMB/SLMB/QI income limit when Medi-Cal rules (MC 176-1 QMB/SLMB/QI) are applied. Use this form only if the QMB/SLMB/QI applicant has an ineligible spouse, with or without children.

• Income can only be allocated to minor children from the gross unearned and earned income of the Ineligible Spouse.

• Complete Section II of the MC 176-2A QMB/SLMB/QI first if there are minor children in the home.

• Subtract the minor child's income from the Standard SSI Allocation. [Refer to Chart Book, “Current Maintenance Need,” page 5-6 for the Standard SSI Allocation, which changes annually.] (Compute separately for each child.)

Revised: 01/09/2017 Update # 2017-01


Note:Using SSI income rules, a minor child is defined as any child under age 18 or 18-21 and a student.

• Determine the income of the ineligible spouse (after allocating to the minor children).

• When the MC 176-2A QMB/SLMB/QI is used, only the QMB/SLMB/QI Income Limit for an individual or couple (one or two) is used.

If the... Then...

Remaining gross income of the ineligible spouse is less than or equal to the Standard SSI Allocation, it is exempt.

Compare only the QMB/SLMB/QI applicant's income to the limit for one. If at or below the QMB limit for one, eligible. If below the SLMB/QI limit for one, eligible.

Remaining gross income of the ineligible spouse is greater than the Standard SSI Allocation

Combine the QMB/SLMB/QI applicant and spouse's income and use the QMB/SLMB/QI limit for two.

Note:Refer to “Current Maintenance Need,” page 5-6 for the Standard SSI Allocation which changes annually.]

30.18.4 IRWE

The actual Impairment Related Work Expenses (IRWE) of a QMB/SLMB/QI applicant/beneficiary which are necessary to become or remain employed can be deducted from his/her earned income only. Such expenses generally include:

• Those required to control a disabling condition thereby enabling the individual to work.

Example:Prescriptions that are needed to control the disabling condition may be covered if they are not paid for by another source. However, routine prescriptions for unrelated medical conditions cannot be deducted from earnings.

• Those essential to perform the physical and/or mental demands of a job. (e.g., wheelchairs, prosthesis, etc.)

• Assistance in preparing for work and traveling to and from, (e.g., attendant care, transportation costs, exterior ramps or railings).

Update # 2017-01 Revised: 01/09/2017


The actual cost to the QMB/SLMB/QI applicant must be verified.

Note:Do not allow IRWE that are being paid (or will be paid) by another source (e.g., Medicare, Medi-Cal, the State Department of Rehabilitation, private insurance).

30.18.5 QMB/SLMB/QI Budgeting Sequence Chart

References to MC 176 forms only apply to manual budgets as CalWIN automatically computes and determines eligibility for these programs.

Family Composition Budget Sequence

Single QMB/SLMB/QI Applicant (no spouse or minor children)

Complete MC 176-1 QMB/SLMB/QI, Columns I and III.

• If the net-nonexempt income is less than or equal to the QMB limit, eligible.

• If the net-nonexempt income is less than the SLMB or QI-1 limit, eligible.

• If over, STOP. Not QMB/SLMB/QI eligible.

QMB/SLMB/QI Applicant with Ineligible Spouse (no minor children)


• If the net-nonexempt income is less than or equal to the QMB limit for 2, eligible.

• If the net-nonexempt income is less than the SLMB limit for 2, eligible.

If not eligible for QMB or SLMB using the MC 176-1 QMB/SLMB/QI, determine QMB/SLMB using the SSI rules. Complete the MC 176-2A QMB/SLMB/QI.

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, the ineligible spouse's income is exempt. Use the QMB/SLMB limit for one.

If not eligible for QMB or SLMB using the SSI rules, determine QI-1 eligibility.

• If the ineligible spouse’s income is NOT exempt, use the MC 176-1 QMB/SLMB/QI to determine QI-1 eligibility. Use the QI-1 limit for two.

• If the ineligible spouse’s income is exempt, use the MC 176-2A QMB/SLMB/QI to determine QI-1 eligibility. Use the QI-1 limit for one.

Revised: 01/09/2017 Update # 2017-01


QMB/SLMB/QI Couple (both potentially QMB/SLMB/QI eligible, no minor children)


• If the net-nonexempt income is less than or equal to the QMB limit for two, eligible.

• If the net-nonexempt income is less than the SLMB or QI-1 limit for two, eligible.

• If over, STOP. Not QMB/SLMB/QI eligible.

QMB/SLMB/QI Couple (both potentially QMB/SLMB/QI eligible with minor children)

Complete MC 176-1 QMB/SLMB/QI using all 3 columns.

• If net-nonexempt income is less than or equal to the QMB income limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB or QI-1 income limit for the MFBU, STOP. Eligible.

If NOT eligible, consider the spouse with the most income as the ineligible spouse. Complete all sections of the MC 176-2A QMB/SLMB/QI (first Section II, then III, and Section I last).

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, after allocating to children, exempt it and use the QMB/SLMB/QI income limit for 1.

• If the ineligible spouse's income is more than the Standard SSI Allocation, count it and use the QMB/SLMB/QI income limit for 2. If over, STOP. Not QMB/SLMB/QI eligible.

Single Applicant with minor children and no spouse

Complete MC 176-1 QMB/SLMB/QI, all columns. STOP.

• If net-nonexempt income is less than or equal to the QMB limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB or QI-1 limit for the MFBU, STOP. Eligible.


Update # 2017-01 Revised: 01/09/2017


QMB/SLMB/QI Applicant with ineligible spouse and minor children

Complete MC 176-1 QMB/SLMB/QI using all 3 columns.

• If net-nonexempt income is less than or equal to QMB income limit for the MFBU, STOP. Eligible.

• If net-nonexempt income is less than the SLMB income limit for the MFBU, STOP. Eligible.

If not eligible for QMB or SLMB using the MC 176-1 QMB/SLMB/QI, determine QMB/SLMB using SSI rules. Complete all sections of the MC 176-2A QMB/SLMB/QI (first Section II, then III, and Section I last).

• If the ineligible spouse's income is less than or equal to the Standard SSI Allocation, after allocating to children, exempt it and use the QMB/SLMB income limit for one.

• If the ineligible spouse's income is more than the Standard SSI Allocation, after allocating to children, count it and use the QMB/SLMB income limit for two.

If not eligible for QMB or SLMB using the SSI rules, determine QI-1 using the MC 176-1 QMB/SLMB/QI and/or MC 176-2A QMB/SLMB/QI. If over, STOP. Not QMB/SLMB/QI eligible.

SSI/SSP Recipient Consider each SSI/SSP person to be in his/her own MFBU. Verify net nonexempt income using the Title XVI-SSI/SSP Information Screen [INQX] when available, or other verification.

SSI/SSP is exempt.

• If countable income is less than or equal to QMB income limit for one, QMB eligible.

• If over the QMB income limit, ineligible.

NOTE: SSI/SSP recipients are NOT eligible for SLMB/QI.


Revised: 01/09/2017 Update # 2017-01


30.19Qualified Disabled Working Individuals (QDWI) Program

30.19.1 Background

The Qualified Disabled Working Individuals (QDWI) Program is federally mandated by Section 6408(d) of OBRA '89. It requires the State to pay Medicare Part A premiums for disabled persons who are under age 65 and who lost their Medicare benefits due to earned income in excess of the Substantial Gainful Activity (SGA) limit. QDWI does not pay any Medicare coinsurance, deductibles, or the Part B premium.

In the past, the State has been notifying counties of potential QDWI eligibles. Rarely will individuals be eligible for this program. At initial implementation, only 15 people statewide were potentially eligible.


The QDWI Program is effective 7/1/90.

Eligibility begins the month of application if all eligibility requirements are met.

Individuals may apply for 3-month retroactive QDWI if they were entitled to Medicare Part A in those months and are otherwise eligible.

30.19.3 Benefit

QDWI eligibles only receive state payment of their Medicare Part A premium. No Benefits Identification Card (BIC) is issued.

QDWI eligibility can be viewed on MEDS, Aid Code 8A, on one of the Special Program screens.

30.19.4 Medicare Part A

QDWI applicants must enroll for the special 1818A Medicare program at Social Security. The initial enrollment period for this program is seven months from the date an individual receives notice from SSA that his/her Part A benefits under the

Update # 2017-01 Revised: 01/09/2017


regular Medicare program will end due to excess earnings. Persons who do not enroll during this initial enrollment period must wait until the general enrollment period, January through March. Their benefits will then start in July.


In order to qualify for QDWI, the applicant/recipient must not be otherwise eligible for any other Medi-Cal program. That is, QDWI may not be approved for any individual who is active on Medi-Cal without a Share of Cost (SOC) or whose SOC has been met. In addition, he/she must meet all of the following eligibility criteria:

Conditions

An individual must be eligible to enroll in Medicare Part A (hospital insurance) only under a special program (1818A) and meet all of the following conditions:

• Has not yet attained age 65

• Has been entitled to Social Security Disability benefits (Title II)

• Continues to have the same disabling physical or mental condition

• Lost Social Security Disability benefits (Title II) due to earnings in excess of the SGA limit.

• Is not otherwise entitled to Medicare.

Note:In CalWIN, enter a Y value in the Eligible to Enroll in Medicare part A under 1818A field of the Collect Medicare Expense Detail window if the client meets the above conditions.

Other Requirements

QDWI applicants must meet all other Medi-Cal Program requirements, including:

• Completion of all appropriate Medi-Cal forms (MC 210, MC 13, etc.).

• Providing any necessary verifications


Revised: 01/09/2017 Update # 2017-01


• Reporting any changes within 10 days (Income reports are not required for ABD-MN households.)


Property Limit

The property limit is twice the Medi-Cal property limit, currently:



QDWI eligibles must be a citizen or a noncitizen who would otherwise be entitled to full-scope benefits if applying for regular Medi-Cal. An undocumented noncitizen who would only get restricted Medi-Cal benefits is not eligible for QDWI.

Income Limit

QDWI eligibles must have income at or below 200% of the Federal Poverty Level (FPL).

Important:

Unlike the QMB/SLMB and other FPL programs, the RSDI COLA received in January is NOT disregarded from January through March. The actual gross RSDI income is used to determine QDWI eligibility.

DUE TO THE EXTREMELY SMALL NUMBER OF POTENTIALLY ELIGIBLE PERSONS, INCOME RULES AND BUDGETING EXAMPLES ARE NOT BEING INCLUDED IN THE HANDBOOK SECTION. CONTACT THE MEDI-CAL PROGRAM COORDINATOR, THROUGH YOUR MEDI-CAL LIAISON, FOR ASSISTANCE IF AN INDIVIDUAL MEETS ALL OF THE ABOVE CRITERIA. ALSO, ADDITIONAL QDWI INFORMATION IS CONTAINED IN THE STATE MEDI-CAL ELIGIBILITY MANUAL, PROCEDURES SECTION 51.

Update # 2017-01 Revised: 01/09/2017


30.20 Medicare Part D Prescription Drug Program

Effective January 1, 2006, Medi-Cal no longer cover prescription drugs for individuals who are dually eligibles (have both Medi-Cal and Medicare) including SSI/SSP individuals and those who are in a Medicare Savings Program (MSP) such as the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and the Qualifying Individual (QI-1) Programs. Instead, the new Medicare Part D Prescription Drug Program will replace most Medi-Cal prescription drug coverage to all persons who are eligible for Medicare Part A and/or Part B. Anyone who is eligible for Part A and/or Part B is eligible for Part D.

30.20.1 Part D Enrollment

Enrollment into Medicare Part D is mandatory for the following populations:

• Dually eligible individuals (have both Medi-Cal and Medicare)• MSP-only individuals, and• SSI/SSP individuals.

To facilitate this requirement, the Department of Health Services (DHCS) will automatically enroll all individuals listed above into a Prescription Drug Plan (PDP). Individuals can also enroll themselves directly into the PDP of their choice.

30.20.2 Prescription Drug Plan (PDP)

As of October 2005, eighteen PDPs have been approved to operate in California. The initial enrollment period is between November 2005 through May 2006. Medicare beneficiaries who choose not to enroll when they first become eligible may have to pay a higher premium if they later decide to enroll in a plan. They will also need to wait until the annual general enrollment period (November 15 through December 31 of each year) to sign up for a plan. Each plan has its own distinct list of covered drugs called a formulary. For this reason, it is important that Medicare beneficiaries select their PDP to ensure that their current prescriptions are covered. Each plan can design their benefit package and has the flexibility to offer supplemental benefits for a higher premium.

Full-scope dual eligible and MSP individuals who do not select a plan will be automatically enrolled into a Prescription Drug Plan (PDP).

Revised: 01/09/2017 Update # 2017-01


• Individuals with Medicare HMOs (e.g. Kaiser Senior Advantage, Secure Horizons, Health Net, etc.) will receive their prescription coverage through their respective plans.

• Individuals with traditional fee-for-service Medicare will be randomly assigned to a Prescription Drug Plan (PDP) if a plan is not selected.

The PDP will notify them by mail once they are enrolled. Dual eligibles and MSPs may change plans at any time after the auto-enrollment if they are dissatisfied with the plan assigned to them.

30.20.3 Enrollment in a Plan

Self-enrollment is encouraged to ensure that selected PDP covers their current prescription drugs. Medicare beneficiaries (or their authorized representatives) can enroll themselves directly in a plan. Plans are required to process applications in a timely manner and the plan must notify the applicant of the acceptance or denial of the enrollment request.

If enrolled... Effective Begin Date of Coverage

Between November 15, 2005 through December 31, 2005

January 1, 2006

Between January 1, 2006 and May 15, 2006 The first day of the month after the month of enrollment.

After May 15, 2006, the annual general enrollment period will be from November 15 through December 31 of each year.

Enrolling in a plan when the person is first eligible means that he/she will pay a lower monthly premium.

Medicare Beneficiaries with Other Health Coverage (OHC)

Persons who have OHC (through employers, retirement plans or unions) that covers prescription drugs can decide whether to continue their existing drug coverage or enroll in a Medicare PDP. Covered individuals can also contact their OHC carriers to get the needed drug comparison. As long as the current OHC plan is at least as good as what is offered by Medicare PDP, he or she will not be subject to the penalty of a higher premium if s/he decides to join the Medicare PDP later. Otherwise, they need to enroll in a Medicare PDP when first eligible to avoid paying a higher premium later on (after the initial enrollment period).

Update # 2017-01 Revised: 01/09/2017


Medicare Beneficiaries who Have Medigap Policies

Medigap policies cover some of the costs that are not covered by Medicare. In most states (except for Minnesota, Massachusetts and Wisconsin), the standardized policies are called Medigap Plans A through J. Some of these Medigap Plans (Plan H, I and J) have drug benefits.

If the Medigap Plan... Then...

Does not provide drug benefits, The Medicare drug coverage will not change.

Provides drug benefits, The Medicare beneficiary can either keep the current Medigap drug benefit or enroll in a Medicare PDP to get drug coverage. He or she can keep the Medigap supplemental coverage.

30.20.4 Costs

The new Part D has a premium of around $37, annual deductible of $250 and copays/coinsurances. The costs will vary depending on which drug plan they choose and some plans may offer more coverage and additional drugs for a higher monthly premium. Unlike Part A or B, there is NO buy-in program for Part D premium. The client must be allowed an income deduction if he/she is paying out-of-pocket Part D premium, deductibles, copays/coinsurances.

Costs/Descriptions Beneficiaries’ Out of Pocket Expenses

Monthly Premium Averages $37/mo.

Annual Deductible up to $250

If the initial prescription cost is ($250-$2,250) 25% of the cost up to $500

If the prescription cost is ($2,250-$5,100) 100% coinsurance not to exceed $2,850

If the prescription cost is greater than $5,100 Greater of 5%, OR $2 after $3,600 spent above

30.20.5 Low Income Subsidy (LIS) Assistance

The LIS provides assistance for the costs of premiums, deductibles and copays. Persons with limited income (below 150% FPL) and resources (single - less than $11,500; couple - $23,000) can get help in paying the costs by applying for the LIS assistance.

Revised: 01/09/2017 Update # 2017-01


Dually eligible full -scope Medi-Cal eligibles (have both Medicare and Medi-Cal including those on SSI/SSP) and those who are MSP eligibles do not need to apply for the subsidy as they automatically qualify and will be approved for LIS assistance. Once approved for LIS, they do not have to pay premiums or deductibles and will have low copays between $1-$5 for prescriptions up to $5,100. There is no copay for prescriptions over $5,100. For institutionalized (in LTC) individuals, there is no copay at all.

Individuals who do not automatically qualify for LIS must apply.

Benefit

Income At or Below 100% FPL

Income over 100% FPL

Income Below 135% FPL and with Limited Resources

Income Over 135% FPL with Higher Resources

Income Below 150% FPL with Higher Resources

Monthly Premium

$0 $0 $0 $0 Sliding Scale

Annual Deductible

$0 $0 $0 $50 $50

Initial Prescription Benefit ($0-$5,100)

$1/$3 copays

$2/$5 copays

$2/$5 copays Maximum 15% coinsurance

Maximum 15% coinsurance

Institutionalized/LTC (excluding waiver programs) individuals pay $0.

100% Coinsurance

N/A N/A N/A N/A N/A

Catastrophic Benefit Period (prescriptions greater than $5,100)

$0 $0 $0 $2/$5 $2/$5

LIS and Medi-Cal Share-of-Cost (SOC) Calculation

Dually eligible beneficiaries with a SOC are eligible for LIS beginning in the first month they meet their SOC. Once approved, LIS eligibility continues through the end of the calendar year. It is not contingent on maintaining eligibility and is not subject to change if there are changes in their income or asset levels.

Update # 2017-01 Revised: 01/09/2017


30.20.6 Responsible Agency

The Department of Health Services (DHCS) or Social Security Administration (SSA) make the LIS eligibility determination, redeterminations and appeals of denials.

30.20.7 Information/Referral Resources

To ensure that clients are referred to the appropriate agency, the following chart is provided:

NAME Area of Expertise Phone Number/ Website

Center for Medicaid Services (CMS)

Part D enrollment/questions

(800) MEDICARE www.medicare.gov

Social Security Administration LIS Applications (800) 772-1213 or local Social Security office www.ssa.gov

Health Insurance and Client Advocacy Program (HICAP)

Help/guidance on PDP selection

(800) 434-0222

30.20.8 Implementation

Intake offices must ensure availability of pre-assembled packets in their respective lobbies to be handed out or sent by mail to those who want an LIS application. Each packet must include the following:

• LIS Cover Page• A Medi-Cal mail-in application• QMB/SLMB/QI-1 application, and• LIS application.

Effective 12/01/05, all Medi-Cal adult or QMB/SLMB/QI-1 intake packets must include an LIS application.

Note: LIS applications are not required on Continuing RD packets.

All Offices

If an individual completes and provides an LIS application (in person or by mail) regardless whether or not the individual submits a Medi-Cal or MSP application, all completed LIS applications must be forwarded to SSA by batch using the

Revised: 01/09/2017 Update # 2017-01


self-addressed envelope included with each LIS application. Each District Office must determine a process for designating a basket for batch purposes. A photocopy of an LIS application is not acceptable. Only original LIS application form must be used. If an individual insists upon an LIS eligibility determination by the State or refuses to have his/her LIS application forwarded to SSA, it must be forwarded in batch to:

DHCS/MEB Attn. MMA Analyst 1501 Capitol Avenue, MS 4607 Post Office Box 997417 Sacramento, CA 95899-7417

Eligibility Staff

Individuals who want to apply for LIS are to be provided assistance. Assistance means (as needed) reading and explaining the LIS application, helping the client in completing the original hard copy LIS application or internet-based application, providing SSA’s telephone number (800) 772-1213 where applications can be completed by phone. Refer Medicare beneficiaries to the appropriate agency (refer to the chart above).

Process Flow

In alignment with the current NBM process, the chart below provides the process flow.

Stage Who Task/Steps

1 Client Requests an LIS application by walking into an intake office or by phone.

Update # 2017-01 Revised: 01/09/2017


30.20.9 Santa Clara Family Health Plan (SCFHP) Medicare Plan

SCFHP offers a Medicare Advantage plan called Healthy Generations (HG). It is for people who:

• Live in Santa Clara County,• Are dually eligibles (have both Medi-Cal and Medicare Part A and Part B).

For additional information, clients can call 1-888-355-5557. For hearing or speech impaired: TTY 1-800-735-2929.

30.21Medicare Plus Choice (M+C) Premium Payment Program

In January 2001, the Department of Health Services (DHCS) began paying Medicare health maintenance organization (HMO) premium amounts on behalf of dually eligible beneficiaries enrolled in medicare HMOs that provided prescription drug coverage. The purpose of those payments was for the State to save money on prescription drugs covered by the Medicare HMOs.

2 CST/OS2 • Gives or mails an LIS packet to the client• Asks the client if s/he also wants to apply for Medi-Cal or

QMB/SLMB/QI-1 Programs.

If the client does not want to apply for Medi-Cal...

No further action is required.

If the client wants to apply for Medi-Cal....

Proceed with the New Business Model (NBM) process 1.0 (Reception) and 2.0 (Registration).

If the client prefers mail-in application, NBM process 3.6 (Medi-Cal Phone/Mail-In Application) applies.

Note: If the client needs assistance in completing the LIS application, refer the individual to the office-designated staff who handles Part D/LIS inquiries.

Stage Who Task/Steps

Revised: 01/09/2017 Update # 2017-01


In January 2006, DHCS implemented changes to prescription drug coverage related to Medicare Part D. Among those changes is the payment of a Phase Down State Contribution for all dually eligible beneficiaries and the transition of payment for Medicare Part D covered drugs from Medi-Cal to Medicare prescription drug plans.That means, DHCS will no longer save money by paying Medicare HMO premiums for dually eligible beneficiaries.

Since this M+C Premium Payment Program no longer exists, the above information is kept for historical reference only. Refer to BENDS #07-01 to continue to allow a Medicare HMO premium.

30.22Low Income Subsidy Applications

The Social Security Administration (SSA) is required to refer Medicare Part D Low Income Subsidy (LIS, also known as Extra Help) applicants to the state for Medicare Savings Programs (MSP) determinations with their consent. In addition to MSP, the State of California elected to also determine eligibility for full Medi-Cal benefits. LIS applicants who require evaluation for MSP and/or Medi-Cal eligibility are referred to the counties via MEDS daily worker alerts.

30.22.1 Application Date

The date of application for Medi-Cal and MSP is the date the applicant filed for LIS Extra Help. This date is displayed on the [LIS1] screen in the APPLICATION-DATE field.

If there is already an existing Medi-Cal/MSP application (pending or active), the application date that would be most beneficial to the applicant must be used.

If the applicant has applied for LIS more than once, all LIS application dates will appear on the [LIS6] screen. Each date is associated with the information received from SSA for that application. Information included in each application (income, resources, etc) must be used to help evaluate Medi-Cal and/or MSP eligibility. The application date(s) not used for Medi-Cal/MSP determination must be denied, either as duplicate application or for not meeting eligibility requirements.

Update # 2017-01 Revised: 01/09/2017


Reminder:The QMB effective date has not changed. QMB eligibility begins the first day of the month following the month in which QMB is authorized in CalWIN.

[Refer to Chapter 1 of the User’s Guide “ILIS - LIS Client Inquiry Request,” page 1-110 for information about the LIS database.]

30.22.2 Denial

Once the application date has been evaluated and the EW determined that the LIS application date provides no benefit in terms of the beginning date of Medi-Cal/MSP eligibility (for clients already active on Medi-Cal/MSP), or that the applicant did not meet other Medi-Cal and/or MSP requirements for that month, the application must be denied.

The notices MC 239 A “Medi-Cal Notice of Action - Denial/ Discontinuance of Benefits” or MC 239K “Medi-Cal Notice of Action - Denial or Discontinuance of Benefits as a Qualified Medicare Beneficiary” may be used. Example of denial reason “Duplicate application, our record shows you are already receiving Medi-Cal benefits” or other appropriate reason(s) may be entered on the NOA.

Note:If the LIS applicant is already active on Medi-Cal and/or MSP in CalWIN, the MC 239 A - LIS DENIAL must be manually printed from the DEBS Forms Library.

30.22.3 Processing Timeframe

Determination of Medi-Cal/MSP eligibility MUST BE COMPLETED WITHIN 45 DAYS from the date the county receives the LIS alert. This date is normally one business day following the COUNTY-REFERRAL-DATE shown on the [LIS1] screen.

30.22.4 Retroactive Benefits

LIS applicants can also apply for retroactive Medi-Cal, SLMB and/or QI-1 benefits from the date of the LIS application. To request retroactive coverage, applicants must have medical expenses for the month(s) requested.

Note:The “Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210 A) must be completed as applicable.

Revised: 01/09/2017 Update # 2017-01

https://ssaconnect.sccgov.org/ssaforms/_layouts/15/WopiFrame.aspx?sourcedoc=/ssaforms/Documents/MC_239_A_LIS%20Denial_en.docx&action=default&DefaultItemOpen=1




30.22.5 Continuing / Pending Cases

If the LIS applicant is currently receiving Medi-Cal and/or MSP benefits, or the LIS applicant has a pending case, the assigned EW will receive an MIPPA LIS alert. The four possible daily alerts are:

• 9056 MIPPA LIS App - Not Current Medi-Cal or MSP Eligible

• 9057 MIPPA LIS App - Current MSP Elig but Not Current Medi-Cal Elig

• 9058 MIPPA LIS App - Current Medi-Cal Elig but Not Current MSP Elig

• 9059 MIPPA LIS App - Current Medi-Cal and MSP Eligible

If one of these alerts is received, refer to User’s Guide, Chapter 11, “County Eligibility Worker Alerts: 9000 - 9999,” page 11-1 for instructions.

30.22.6 Intake Process

If the LIS applicant cannot be matched to a record on MEDS, the following daily alert will be generated:

• 9055 MIPPA LIS App - No Matching Record Found on MEDS

Follow the steps below when the LIS applicant does not have a MEDS record:

Step Who Action

1. Info Systems On a daily basis, posts Alerts 9055 in a report titled “Low Income Subsidy Applications” in Business Objects (BO) under Public Folders/DEBS/ AAC_A5 and VMC/Administration.

Update # 2017-01 Revised: 01/09/2017


2. Designated Clerical Staff at VMC

• Prints the “LIS Applications” report from BO daily.• Completes file clearance procedures in CalWIN and MEDS.

For individuals that already have an active or pending case:

• Sends an e-mail notification to the current EW and cc’s the EW supervisor. On the subject line, enters “Urgent - LIS Alert 9055”.

• For applicants with the same last name, checks address on the [LIS2] screen to see if they are spouses. If they are, app reg them in the same case.

For individuals who do not have an active or pending case:

• Completes the Application Registration process in CalWIN.

• Use the APPLICATION-DATE shown on the [LIS1] screen.

• Select “Low Income Subsidy” from the Application Source drop down field.

• Assigns the application to VMC Caseload # DMZ0.

• Prints and signs a copy of “Application For Cash Aid, Food Stamps, And/or Medi-Cal” (SAWS 1).

• Creates an application packet consisting of the following form and MEDS screens and forward to VMC:

• Application for Cash Aid, FS and/or MC (SAWS 1)• Primary Medi-Cal/CMSP Information Screen (INQM)• Other Client Eligibility Information Screen (INQE)• LIS Inquiry, Client Data Screen (LIS1)• LIS Inquiry, Client Information Screen (LIS2)

Step Who Action

Revised: 01/09/2017 Update # 2017-01


3. Designated VMC Clerical Staff

• Sends the Medi-Cal Application with the following two packets of forms to the applicant along with a pre-addressed, postage paid envelope. Enter name, case # and due date (10 calendar days from current date) on the SCD 2269 and SCD 2270. SIGNATURE PACKET:

• Important Info on MC/MSPs (SCD 2269)• Supplemental Questions for MC/MSP (SCD 2270)• Statement of Citizenship/Alien Status (MC 13)• Notice Regarding Standards for MC Elig (DHCS 7077)• Notice Regarding Transfer of a Home (DHCS 7077 A)• Would You Like to Register to Vote (SCD 508).

INFORMATIONAL PACKET:

• Important Info for Persons Requesting MC (MC 219)• Important Info for Nursing Home Patients (MC 004)• Medi-Cal General Property Limitations (MC 007)• Important Info MC Beneficiaries-LTC (MC18)• Breast & Cervical Cancer Treatment (MC 372)• Medi-Cal What It Means to You (PUB 68)• Keep Your Medi-Cal on Target (SCD 391)• Papers Needed for MC Determination (SCD 1481)

•

4. Designated Clerical Staff at VMC

• Sends a CalFresh application packet along with the form “Good News for Seniors Receiving Social Security Benefits” (SCD 2329) and an AAC pre-addressed, postage paid envelope.

If the client returns the...

Then the application is processed...

Medi-Cal application, At VMC following the instructions outlined in step 5.

CalFresh application, At AAC following the usual procedures for a new CalFresh application.

NOTE: If a Medi-Cal application is pending at VMC, this will be transferred to AAC. At this point, both CalFresh and Medi-Cal applications will be processed at AAC.

Step Who Action

Update # 2017-01 Revised: 01/09/2017


30.22.7 Documentation

The result of Medi-Cal and/or MSP eligibility determination must be clearly documented in the Maintain Case Comments window, including the reason of the denial if the LIS application is denied.

5. Intake EW Follow the procedures below to process the LIS application:

If the applicant... Then...

Returns the SCD 2269 or calls and reports that he/she does not want Medi-Cal or MSP,

Withdraw the application as it is considered a written withdrawal.

Does not return the SCD 2269 or SCD 2270 or provide information by phon by the due date OR the mail comes back as returned mail,

Denies the application for failure to cooperate or whereabouts unknown, as appropriate.

Returns the SCD 2270 (with or without the SCD 2269), or only the SCD 2269 but marks just one check box,

OR

Calls to report information but does not provide necessary verification,

• Reviews LIS screens in MEDS and the SCD 2270 questionnaire.

• Requests additional information and verification from the client, if necessary. Allows 10 calendar days to provide. Documents in the Maintain Case Comments window.

• If the applicant is ELIGIBLE, approves Medi-Cal/MSP using the Application Date shown on the [LIS1] screen.

• If the applicant is INELIGIBLE, denies Medi-Cal/MSP with an appropriate NOA.

Step Who Action

Revised: 01/09/2017 Update # 2017-01


30.22.8 Forms

Since SSA began the application process, a new application is not required. The following forms are used to request information, but are not required. The information can be provided over the phone.

SCD 2269

The “Important Information on Medi-Cal and Medicare Savings Programs” (SCD 2269) is sent to the LIS applicant if he/she is not currently receiving Medi-Cal and/or MSP. This cover letter inquires whether the individual wishes to opt-out of Medi-Cal and/or MSP.

SCD 2270

The “Supplemental Questions for Medi-Cal/MSP Application” (SCD 2270) is sent to client together with the SCD 2269. It is used to request information about family composition, earnings, and resources as well as other health coverage.

Update # 2017-01 Revised: 01/09/2017


Revised: 01/09/2017 Update # 2017-01

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