DPSS ePolicy

To convert existing policy to new webpage – No content changes.

Revision of existing policy and/or form(s).

What changed?

1. Clarification regarding the Annual Renewal (RE) process for individuals receiving Supplemental Security Income/Supplemental Security Payments (SSI/SSP) and Medicare Savings Programs (MSP) - Qualified Medicare Beneficiary (QMB).
2. The MC 14A, Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individuals Application, dated 9/2019, has been revised.
3. Partial information previously released in Medi-Cal Program (MCP) Call-Out MCP 18-21, New Medicare Beneficiary Identifier (MBI) Number, dated 4/4/ 2018, and Call-Out MCP 18-31, Update – New Medicare Beneficiary Identifier (MBI) Number, dated 6/21/2018, has been incorporated into this document.
4. Updated property limits for MSP.
5. The California Statewide Automated Welfare System (CalSAWS) will now grant conditional eligibility to QMB benefits for Conditionally Eligible Medicare Part A individuals whose entitlement to Medicare Part A begins July 1.
   • QMB applications/referrals received for these individuals can be processed in the month received.
   • New Notice of Action (NOA) has been programmed when these benefits are approved.
   • How-To-Guide No. 8, Update MSP Cases in CalSAWS will be updated/released in the near future with updates related to these changes.
6. How to report Medicare buy-in issues.
   • Submitting report on-line.
   • Discontinuance of the Department of Health Care Services (DHCS) form, DHCS 6166, State Medicare Buy-In Problem Report.
7. A reminder that SSI/SSP-MSP applicants/beneficiaries are not required to provide verification of property, as they meet the property limits through the Social Security Administration (SSA).

The MSPs are federally-mandated programs for Medicare beneficiaries.  Counties are mandated by federal requirements to conduct MSP evaluations for all Medi-Cal applicants/beneficiaries receiving Medicare.

Medicare eligible individuals may apply for Medi-Cal and MSP or MSP-Only.  Depending on the MSP, an individual qualifies for benefits that include payment of premiums, deductibles, and co-insurance fees.

MSP has four separate programs:

QMB

1. Covers cost-sharing expenses of Medicare coverage including premiums, deductibles and co-insurances fees.
2. Pays for Part A and Part B premiums. 

Specified Low-Income Medicare Beneficiary (SLMB)

1. Does not pay deductibles or co-insurance fees.
2. Pays for Part B premiums.

Qualifying Individual - 1 (QI-1)

1. Does not pay deductibles or co-insurance fees.
2. Pays for Part B premiums.

Qualified Disabled Working Individual (QDWI)

1. Applies to certain qualified disabled individuals who lost Title II (Social Security Disability) and Medicare benefits due to earned income above the required Substantial Gainful Activity (SGA) limit.
2. Does not pay deductibles or co-insurance fees.
3. Pays for Part A premiums.

As a result of the Affordable Care Act, individuals enrolled in Medicare Part A or B are not eligible for the new Modified Adjusted Gross Income (MAGI) Medi-Cal program under the adult expansion group.  This includes individuals 19-64 years of age.  However, a Medicare recipient who is a parent/caretaker relative, child, or a pregnant person may be eligible for MAGI Medi-Cal.

Medicare is a national health insurance program administered by SSA. Medicare Part A covers hospital insurance and Medicare Part B covers medical insurance.  While many Medicare beneficiaries receive free Part A coverage, some beneficiaries are required to pay a premium.  Medicare Part B is not free and always requires a premium payment.

The Medicare Catastrophic Coverage Act of 1988 required certain changes in the Medi-Cal program.  One of those changes required that States pay the Medicare Part A and Part B premiums for low income Medicare beneficiaries.

The State receives Federal Financial Participation (FFP) for those individuals enrolled in an MSP; therefore, it is important to ensure timely and accurate eligibility determinations for all Medi-Cal applicants/beneficiaries.

Medicare Eligibility

SSA determines eligibility to Medicare.  To be eligible for MSP, the individual must be entitled to or be receiving Medicare and meet the requirements below.

MSP Program/Aid Code and Eligibility Requirements

QMB applicants - Aid Code 80

Must be enrolled or entitled (Conditionally Eligible) to Part A.

Notes: 

Applicant may be:

• QMB–Only,
• QMB and Medi-Cal eligible, or
• QMB/SSI/SSP eligible.

SLMB applicants - Aid Code 8C

Must be enrolled or entitled to Part A and B.

Notes: 

1. Applicant is ineligible to QMB due to excess income.
2. Applicant may be:
   • SLMB-Only, or
   • SLMB and Medi-Cal.

QI-1 applicants - Aid Code 8D

Must be entitled to Part B.

Notes:

1. Applicant is ineligible to SLMB due to excess income.
2. Applicant may be:
   • QI-1-Only, or
   • Q-1 and Medi-Cal.
     • An applicant is not eligible for QI-1 if they are eligible for any other zero Share of Cost (SOC) Medi-Cal.

Note:  To be eligible to QI-1 the applicant will have a SOC.

QDWI applicants - Aid Code 8A

Applicant must:

1. Be eligible to enroll in Part A.
2. Be under 65 years of age.
3. Have been entitled to disability insurance benefits under Title II (SSA).
4. Have lost Title II (SSA) benefits due to earnings which exceeded the SGA limit.
5. Continues to have a disabling physical or mental condition.
6. Not be otherwise eligible to Medicare.
   

Notes:

1. SSA will refer a potential QDWI eligible individual to our department when they meet the QDWI criteria.
2. Applicant may be:
   • QDWI-Only
   • QDWI and Medi-Cal

Property Limits

MSP property limits are higher than Medi-Cal property limits.  If the Medicare recipient does not qualify for Medi-Cal because they are over the Medi-Cal property limit, they can still be evaluated for MSP-Only.

Note:  MSP property limits change each year and are released via the annual Federal Poverty Level (FPL) Chart released by MCP.

MSP-Only (2020 property limits)

• $7,860 for one person, and
• $11,600 for a couple

Note:  Staff should refer to the annual FPL Chart for updates to the MSP property limits.

Medi-Cal and MSP

• $2,000 for a single person, and
• $3,000 for a couple

Income

• QMB - Income at or below 100% of the FPL.
• SLMB - Income between 101% of the FPL up to 120% of the FPL.
• QI-1 - Income between 121% of the FPL up to 135% of the FPL.
• QDWI - Income between 136% of the FPL up to 200% of the FPL.

A couple found ineligible to MSP due to exceeding income has the option of:

• One spouse being evaluated for MSP, and
• The other becoming an MSP ineligible spouse. 

Residency

• Individual must meet California residency requirements.

Citizenship

• Individual must be a citizen or non-citizen with satisfactory immigration status.

Benefits Identification Card

• QMB – Beneficiary receives a Benefits Identification Card (BIC).
• SLMB – Beneficiary does not receive a BIC unless also eligible to another Medi-Cal program.
• QI –1 Beneficiary does not receive a BIC unless also eligible to another Medi-Cal program.
• QDWI – Beneficiary does not receive a BIC unless also eligible to another Medi-Cal program.

MSP Effective Date of Eligibility

QMB

Initial Enrollment Period

Medicare eligible individuals applying for QMB during their initial enrollment period may be eligible to benefits effective the first day of the month following the date of QMB approval, if otherwise eligible.

Example:  A Medicare eligible individual applies for QMB on 1/15/2020.  Upon approval, QMB benefits will begin the first day of the following month (2/01/2020).

General Enrollment Period - Conditional Enrollee

Conditional enrollees applying for QMB prior to July will have benefits approved effective July of that year, if otherwise eligible.

Example:  Conditional enrollee applies for QMB on 5/23/2020.  QMB benefits must be approved effective 7/01/2020.

SLMB/QI-1/QDWI

Medicare eligible individuals applying for SLMB/QI-1/QDWI, may be eligible effective the month of application, if otherwise eligible.

Example:  Medicare eligible individual applies for SLMB/QI-1/QDWI benefits on 5/12/20.  Upon approval, benefits will begin effective 5/01/2020.

MSP Retroactive Coverage

A beneficiary who qualifies for MSP, with the exception of QMB, may be eligible for retroactive coverage if otherwise eligible.

• If eligible for QMB, then applicant(s) is not eligible to retroactive QMB coverage.
  Note:  Per MSP/QMB policy, QMB benefits are effective the first of the month following the date of approval.  There are no retroactive QMB benefits.
• If eligible for SLMB/QI-1, then applicant(s) is eligible for up to three months of retroactive SLMB/QI-1 benefits, if otherwise eligible.
• If eligible for QDWI, then applicant(s) is eligible for up to three months of retroactive QDWI benefits if they are entitled to Part A benefits in the retroactive period, if otherwise eligible.

MSP Applications (Intake)

Refer to the following section to determine what application is required for MSP.

• If individual is receiving SSI/SSP and applying for MSP, then:
  1. Accept referral from SSA if one is available.  However, a referral from SSA is not needed if Medicare eligibility is confirmed.  Refer to Verification Documents section.
  2. An MC 14A, Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individuals Application, is required at Intake; however, verification of income and property is not required, nor should it be requested, as SSI/SSP individual(s)/couples meet these requirements through SSA.
     Note:  Staff is reminded that verification of property must not be requested or pended in CalSAWS for SSI/SSP beneficiaries applying for/eligible to MSP-QMB.  See Important Reminders:
• If individual is applying for Non-MAGI Medi-Cal and MSP, then the Single Streamlined Application and MC 604 IPS, Additional Income and Property Information Needed for Medi-Cal.
• If individual is applying for MAGI* Medi-Cal and MSP, then the Single Streamlined Application and MC 604 IPS, Additional Income and Property Information Needed for Medi-Cal.
  *Parent/Caretaker Relative within 109% of FPL
• If individual is applying for MSP-only, then the MC 14A, Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, or Qualifying Individual Application.

Notes:

1. Your Benefits Now (YBN) is currently not programmed to accept MSP-Only applications.
2. MSP applications must be processed within the standard 45-day timeframe.
3. Always ensure to conduct an ex-parte review, if applicable.
4. Staff must follow standard procedures regarding the additional Informational Notices that must be provided with an Intake/RE packet issued manually.  Refer to the following policy documents:
   • Administrative Directive 5694, Medi-Cal Renewal Policy, dated 2/7/2019
   • Administrative Directive 5846, Non-MAGI Application Supplemental Packet, dated 6/30/2020
   • Administrative Directive 5793, Medi-Cal Application (Intake) Packet, dated 8/20/2020

MSP Annual RE

An RE is required for beneficiaries who receive MSP-Only, Medi-Cal and MSP, and SSI/SSP-MSP.

• If beneficiary is MSP-Only eligible, then MC 14A, Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, or Qualifying Individual Application.
  Note:  Staff can refer to Administrative Directive 5846, Non-MAGI Application Supplemental Packet, dated 6/30/2020.
• If beneficiary is Non-MAGI Medi-Cal and MSP, then the MC 210 RV, Medi-Cal Annual Redetermination Form is required.
• If beneficiary is SSI/SSP eligible and MSP, then:
  1. An RE packet is not required; therefore, a packet will not be mailed to an SSI/SSP-MSP beneficiary nor should staff mail one to the beneficiary.
  2. An ex-parte review must be conducted.   See Procedures.
• If beneficiary is SLMB/QI-1/QDWI eligible, then the MC 14A, Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, or Qualifying Individual Application.
  Note:  If beneficiary is also receiving Medi-Cal, the Medi-Cal RE meets the SLMB, QI-1 or QDWI RE requirement.
• If beneficiary is LTC and MSP, then the MC 262, Redetermination For Medi-Cal Beneficiaries Long-Term Care In Own Medi-Cal Family Budget Unit.
• If beneficiary is MAGI Medi-Cal and MSP, then the MC 216, Medi-Cal Renewal Form and MC 604 IPS, Additional Income and Property Information Needed for Medi-Cal.
  *Parent/Caretaker Relative within 109% of FPL

Notes:

1. Annual REs must be processed by no later than the end of the RE due month.
2. REs can be submitted:
   • In person
   • By Mail
   • By fax
   • Online via YBN online portal
   • By telephone

Refer to Administrative Directive 5822, Telephonic/Electronic Signature Requirements for Medi-Cal, dated 6/24/2020.

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