016.20.02 Ark. Code R. § 021 - Medical Services Policy MS23000 and DCO-912; ARSeniors Waiver Program; End of Qualified Individuals 2 (QI-2) Program; and Increase in Income Limit for ARSeniors Medicaid to 80% FPL
Since 1988, several laws have been passed requiring states to provide savings to certain Medicare recipients through the state's Medicaid program. The categories enacted are Qualified Medicare Beneficiaries (QMB) including ARSeniors and ARxSeniors for certain Aged QMBs, Specified Low-Income Medicare Beneficiaries (SMB), Qualifying Individuals - 1 (QI-1), and Qualified Disabled and Working Individuals (QDWI). These categories provide Medicare savings by paying the Medicare premium(s) or a portion of the Medicare premium and possibly the Medicare deductibles and coinsurance. Except for ARSeniors, these categories do not pay for the full range of Medicaid services.
The comparison chart on the next page provides a brief overview of the six categories including the coverage provided and eligibility requirements.
|
ARSeniors |
ARxSeniors |
QMB |
SMB |
QI-1 |
QDWI |
|
|
Benefits |
Full Range of Medicaid Benefits |
Provides QMB benefits plus 2 Rx drugs with cost-sharing |
Pays Medicare Premium(s), deductible and coinsurance |
Pays Part B Premium |
Pays Part B Premium |
Pays Part A premium |
|
Categorical |
Aged Only |
Aged Only |
Aged, Blind or Disabled |
Aged, Blind or Disabled |
Aged, Blind or Disabled |
Blind or Disabled |
|
Income Limits |
Equal to or below 80% of FPL |
Greater than 80%, but equal to or less than 90% of FPL |
100% of the Federal Poverty Level (FPL) |
Between 100% and 120% of FPL |
At least 120% but less than 135% of FPL |
200% of FPL |
|
Resource Limit |
Individual Couple |
$4000.00 $6000.00 |
||||
|
Certified in other category at same time? |
No |
Yes |
Yes |
Yes |
No |
Yes |
|
Medicare Requirements |
Must receive Medicare if entitled to Medicare |
Entitled to or conditionally eligible for Medicare Part A |
Entitled to or conditionally eligible for Medicare Part A |
Entitled to (actual Medicare Part A |
ly receiving) and B |
Lost Medicare Part A & SSA-DIB benefits due to SGA Entitled to reenroll in Medicare Part A |
|
Policy Re: |
MS 23100 |
MS 23100 |
MS 23100 |
MS 23100 |
MS 23100 |
MS 23500 |
ARSeniors for Aged QMBs provides full Medicaid coverage. It is the only coverage group in the Medicare Savings categories that provides the full range of Medicaid benefits. If applicants for ARSeniors Medicaid are eligible in the month of application, they can also receive retroactive coverage for the three months prior to application, if otherwise eligible. However, retroactive benefits cannot begin prior to November 1, 2002.
ARxSeniors for Aged QMBs provides two prescription drugs with cost-sharing in addition to regular QMB benefits. The co-payment for the two prescription drugs will be $10.00 for generic and $20.00 for name brand drugs. In addition to the co-payment, there will be an enrollment fee of $25.00 per state fiscal year (SFY). The enrollment fee will be paid at a rate of $5.00 per prescription in addition to the recipient co-payment. The enrollment fee amount will be deducted electronically from the price of the prescription and collected by the pharmacy provider at the time of purchase until the recipient is credited with the full amount of $25.00 during the SFY.
QMB pays all Medicare premiums, deductibles, and coinsurance. There is no retroactive coverage for QMBs. Coverage of Medicare premiums, deductibles, and coinsurance will begin on the first of the month following the month of approval in the QMB category.
SMBs are eligible for the payment of Medicare Part B premiums only. No other Medicare cost sharing charges will be covered. SMBs, are, however, eligible for retroactive benefits for up to 3 calendar months prior to application, if the individual meets all SMB eligibility requirements in the retroactive period. Coverage must begin on the first day of the month. Individuals who qualify for SMB will not receive a Medicaid card
QI-1s are eligible for payment of their Medicare Part B premiums only. QI-1s are eligible for retroactive benefits for up to 3 calendar months prior to application if the individual meets all eligibility requirements. Coverage must begin on the first day of the month. However, retroactive coverage cannot begin before January 1 in the current calendar year. QI-1s will not receive a Medicaid card.
ARSeniors, ARxSeniors, QMBs, SMBs and QI-1s must all meet the same basic eligibility requirements. Self-declaration will be accepted for all eligibility requirements with the exception of alien status of non-citizens. Eligibility requirements are as follows:
|
Individual |
$4,000 |
|
Couple |
$6,000 |
Countable resources are determined according to LTC guidelines (Re. MS 3330-3337). Caseworkers will determine resource eligibility based on what is self-declared on the application.
ARSeniors - equal to or less than 80%
ARxSeniors - greater than 80% but equal to or less than 90%
QMB - equal to or less than 100%
SMB - between 100% to 120%
QI-1 - at least 120% but less than 135%
Countable income is determined according to LTC guidelines (Re. MS 3340 -3348). Self-declaration will be accepted. However, the caseworker will be responsible for requesting a SSA Query before certification. In-Kind Support and Maintenance is considered in ARSeniors, ARxSeniors, QMB, SMB andQI-1 determinations. For a couple, total monthly countable income will be compared to the couple's standard in each case. If only one spouse is eligible, the procedures for deeming of income at MS 2111-2111.5 will apply.
Individuals applying for Medicare Savings coverage only will not be required to apply for SSI if their income is less than the SSI/SPA (Re: SSI Chart at Appendix S). If an individual does not wish to be referred to SSA and does not want to be certified for full Medicaid benefits in another Medicaid category, he/she may be certified for Medicare Savings coverage only.
Self-declaration will be accepted for all eligibility requirements with the exception of alien status of non-citizens. Alien status must always be verified. If the declared income and resources are within the allowable amounts for the program, the client's declaration will be accepted. The caseworker, will however, complete a SSA Query on all applicants to confirm the accuracy of the gross benefits, Medicare claim number, and Medicare Part-A entitlement. If the applicant declares resources, the value of which would make him/her ineligible, and the caseworker cannot determine if the resource is countable (such as a life insurance policy or burial plan), the caseworker should then contact the applicant to determine if the resource is countable. The client's statement of the type of resource and the resource value will be accepted and documented. If it cannot be determined through contact with the client if the resource is countable, the client should be given the opportunity to provide a copy of the resource document.
Individuals who apply for ARxSeniors, QMB or SMB coverage and have medical expenses in prior months may be considered in other Medicaid categories (including spend-down categories) for the retroactive coverage.
Except for Medicaid Spend-downs, an individual may not be certified in a QMB or SMB category and in another Medicaid category for simultaneous periods. If an individual is eligible in a category other than QMB, he will be eligible for and receive the QMB benefits along with other Medicaid benefits (Re MS 23150). If an individual could be eligible in either a QMB category or a non-QMB category, the individual should be approved in the non-QMB category.
Example: An individual eligible for both an Aid to the Disabled and a Disabled QMB category will be certified in the Aid to the Disabled category, but will receive full QMB benefits. An individual may be approved for a spend-down and a QMB for simultaneous periods.
Example: An individual applies for QMB coverage and for other Medicaid categories on March 1, and has sufficient non-coverable medical bills for a spend-down period of March, April, and May. QMB coverage is approved on March 30. QMB coverage will begin April 1. For any concurrent months of QMB and spend-down eligibility, Medicare premiums may not be considered as a non-coverable medical expense.
Unlike QMBs and SMBs, QI-1s may not be certified in any other Medicaid category for simultaneous periods. An individual who is eligible for QI-1 and a spend-down will have to choose which coverage is wanted for a particular period of time.
ARSeniors do not have to be eligible for Medicare entitlement. QMBs and ARxSeniors must be entitled to or conditionally eligible for hospital insurance benefits under Medicare Part A. SMBs and QI-1s must be entitled to (receiving) Medicare Part A. Medicare Part A beneficiaries include the following groups:
Individuals who are conditionally eligible fall into this group, except that they are not receiving Part A Medicare because they cannot afford to pay the premium for Part A.
Entitlement to Part B Medical Insurance only does not constitute eligibility for QMB, SMB or QI-1. An individual must also be entitled to Part A for SMB or QI-1and entitled to or conditionally eligible for Part A to be eligible for QMB.
Individuals Entitled to Part A Without Payment of Part A Premium
A person entitled to Social Security retirement benefits or a qualified Railroad Retirement beneficiary is automatically eligible for hospital insurance beginning with the first day of the month of attainment of age 65, but the individual must apply with SSA in order to be enrolled in Part A Medicare.
An individual who fails to enroll for Medicare upon attainment of age 65 may enroll during the General Enrollment Period (January through March of each year). If the individual enrolls during the General Enrollment Period (January through March), coverage starts on July 1 following enrollment.
Individuals Who Would Be Entitled to Part A if They Could Pay Part A Premiums (Conditional Eligibles - applies to QMBs and ARxSeniors only)
An individual already receiving Part B Medicare may have a QMB eligibility determination made without going to SSA to apply for Part A. If found QMB eligible and certified by the County, the individual will become entitled to Part A Medicare (and all other QMB benefits) when the system accretes the individual and the State Medicaid Agency begins paying the Part A Medicare premiums. The system accretions for these individuals and for SSI QMB eligibles may be made at any time of the year, i.e., they do not have to be done during a general enrollment period or at any other specified time.
An individual not receiving Part A or Part B Medicare must first go to SSA to apply for Medicare benefits. If SSA determines an individual will meet the Medicare requirements the individual may be referred to DHS for a QMB eligibility determination. Proof of Part B entitlement must be established before an application can be processed. If the individual is not entitled to Part B, the application will be denied. If the client does not provide proof of entitlement (Medicare card, SSA award letter, etc.) the caseworker will submit a Query to SSA, or contact SSA for verification of entitlement.
Application will be made on the DCO-808 or DCO-777 by the applicant, an authorized representative, or a person acting responsibly on his or her behalf.
After completion, the application will be mailed or taken to the local DHS County office for processing. The applicant will not be required to visit the local DHS county office for an interview.
Only one application will be required when both members of a couple apply.
Forms to be completed at application are the application form DCO-808 or DCO-777, DCO-86 and DCO-662 (ARSeniors, ARxSeniors and QMB only).
Applications will be registered on the computer system.
The caseworker will process the application by approval, denial, or withdrawal within 45 days. Applications requiring an MRT decision (e.g., when a Medicare Part A beneficiary under age 65 is receiving Railroad Retirement benefits based on a disability) should be completed within 90 days.
After all SSI exclusions have been deducted from current income, the net countable income will be compared to the current ARSeniors income level for Aged individuals. If the individual's income is at or below the ARSeniors income level, he/she is eligible for Medicaid benefits as an ARSeniors recipient. If income exceeds the ARSeniors income level, income will be compared to the ARxSeniors income level. If the individual is at or below the ARxSeniors income level, he/she is eligible for ARxSeniors benefits.
If the individual is not aged, or if the aged individual's income is above the ARxSeniors level, income should be compared to QMB limits, and then to the SMB and QI-1 limits if necessary. If the individual has an ineligible spouse, countable income will be determined according to MS 2111.1, and the net income will be compared to the couple's ARSeniors, ARxSeniors, QMB, SMB or QI-1 income level.
If eligibility is to be determined for both members of a married couple, total their current income, subtract the $20.00 exclusion per couple and other applicable SSI exclusions to arrive at their countable income. This income will be compared to the couple's ARSeniors, ARxSeniors, QMB, SMB or QI-1 income level to determine eligibility.
Individuals eligible for ARxSenior benefits will not automatically be approved in the ARxSeniors category following QMB approval. The individual will be given the opportunity to choose or reject the prescription drug benefits provided by ARxSeniors. Having coverage for the two prescription drugs may cause the individual to be ineligible for some of the prescription drug assistance programs offered by various pharmaceutical companies. If the individual rejects the ARxSeniors coverage, he/she will still be eligible for the basic QMB coverage. When the case is approved for QMB, the DCO-912, ARxSeniors Selection Form, will be sent to the client asking him/her to choose either ARxSenior or regular QMB coverage. The selection notice will explain the possible consequence of choosing ARxSeniors. The client must return the form indicating his/her choice on the check-off box before receiving the extended ARxSenior benefit. If the form is not returned, the individual will continue to receive QMB coverage only.
Persons who are Medicaid eligible in a category that provides full Medicaid coverage and who are entitled to Medicare Part A will receive the same Medicare cost-sharing coverage as QMBs in addition to their other Medicaid benefits. County offices need not take any action on these cases (for QMB eligibility or coverage) unless Medicaid eligibility in the other category ends.
When Medicaid eligibility in a category other than a Medicare Savings category ends for an individual who is still entitled to Medicare Part A, eligibility for Medicare Savings will be determined based on information available to the county office. A new application will not be obtained from the individual. ARSeniors, ARxSeniors, QMB, SMB, or QI-1 eligibility should be determined and the case certified (if eligible) in the month that the non-QMB related case was closed. If eligible, coverage will begin on the first of the month following certification. When certifying the Medicare Savings case, re-key the original reevaluation date in the computer system.
Examples:
When the annual SSA COLA increases are received in January each year by Medicare Savings recipients, counties will disregard the COLA increases until the new Federal Poverty Limits are issued in that year, even if the SSA COLA increase puts the individual or couple over the current allowable income limits.
When the new Medicare Savings income eligibility limits, based on revised poverty levels, are received, counties will compare the individual's or couple's current countable income (including the January COLA increases) with the revised Medicare Savings income levels to determine if eligibility will continue for April 1st and beyond.
If the individual or couple is ineligible due to the COLA increase, a DCO-700 or DCO-55 will be sent as advance notice of closure, and the case will be closed when the period expires.
The January SSA Cost of Living Adjustment will also be disregarded in determining initial eligibility for Medicare Savings applicants for the period of January 1st through March 31st of each year. Eligibility must then be redetermined for April 1st and beyond, using the new Medicare Savings income limits and the increased SSA amount which includes the January SSA COLA amounts.
ARSeniors, ARxSeniors, QMB, SMB and QI-1 reevaluations will be conducted on an annual basis. At reevaluation, all eligibility factors will be redetermined (Re. MS 23110). Self-declaration will be accepted. The recipient will not be required to attend an interview. Completion of the application form DCO-808 or DCO-777, DCO-662 (for ARSeniors, ARxSeniors and QMB only), and DCO-75 is necessary at each reevaluation.
When a change occurs that affects eligibility, a ten day advance notice of closure, via Form DCO-700 or DCO-55, will be given, unless advance notice is not required (Re. MS 3633). The caseworker will enter data into the computer system to end Medicare Savings eligibility effective the date the notice expires.
At reevaluation or other times when the case is updated, the caseworker should be aware of the Aged QMB recipient's net countable income, noting whether the income is above or below 80% and 90%. When an ARSenior recipient's net countable income increases to over 80% or an ARxSeniors income increases to over 90%, but he/she remains QMB eligible, ARSeniors or ARxSeniors benefits respectively will end the day the new income is keyed to the system. A 10-day advance notice will be sent to the recipient explaining the reduction in benefits, and the change will not be keyed until after the notice period has ended. If an individual has a reduction in income that causes him/her to be eligible in a coverage group with increased benefits, a notice should be sent explaining the new benefits. If the reduction in benefits causes the individual to be eligible for ARxSeniors, the DCO-912 must be sent explaining the choice for ARxSeniors or regular QMB benefits.
Section 6408 of the Omnibus Budget Reconciliation Act of 1989 requires State Medicaid Agencies to pay the Hospital Insurance - Medicare Part A - premium for certain individuals who lost Medicare Part A entitlement solely due to the individual's earnings that reach or exceed the Substantial Gainful Activity (SGA) amount.
These provisions were effective July 1, 1990
Qualified Disabled and Working Individuals (QDWI's) are not eligible for Medicaid services. QDWI's are eligible only for payment of their Hospital Insurance - Medicare Part A - premium. These individuals will not receive a Medicaid card.
Application for QDWI will be made by the individual requesting assistance, or his/her authorized representative, at the DHS County Office located in the individual's county of residence.
Forms to be completed at application are the DCO-777, and DCO-86.
Applications will be registered on the computer system.
A separate application will be taken and registered in the appropriate category for each individual when both members of a married couple apply.
The Caseworker will have a maximum of 45 days to dispose of the application by either approval, denial, or withdrawal.
The following requirements must be met by an individual to qualify for benefits as a QDWI:
Verification that the individual's blindness or disability is continuing; that the individual's entitlement to SSA-DIB and Medicare Part A was lost solely due to SGA; that the individual has reenrolled for Medicare Part A; and the effective date of Medicare Part A coverage will be made by requesting the individual to provide any notices received from SSA. If the individual does not have the necessary verification, he/she will be instructed to obtain the needed verification from SSA. The County Office will contact SSA if the individual cannot obtain the necessary verification.
|
Individual |
$4,000 |
|
Couple |
$6,000 |
Resources will be determined according to LTC guidelines (RE. MS 3330-3337). There will be no penalty imposed for transfer of resources.
Each eligibility factor will be verified by the Caseworker and documented in the case narrative.
The income of an ineligible spouse will be deemed to the QDWI applicant (Re. MS 2111-2111.5) and the net income compared to the couple's QDWI limit.
The income of an eligible couple will be totaled, and SSI exclusions will be given (only one $20 exclusion). The net income for the couple will be compared to the couple's QDWI income limit.
The income of QDWI's may vary monthly due to their income from employment. MS 3343 will be utilized in the determination and verification of earnings from employment.
A QDWI applicant must reenroll for Medicare Part A, if he/she has not previously reenrolled prior to making application.
The Social Security Administration will send notices to those individuals who lost or will lose Medicare Part A solely due to SGA, advising them to contact the SSA office. Once reapplication has been made for Medicare Part A, SSA will refer potentially eligible individuals to the County Office to make a QDWI application.
If an individual applies at the County Office prior to reenrolling for Medicare Part A, the individual will be instructed to go to the SSA Office to reenroll for Medicare Part A and provide verification of reenrollment and the effective date of coverage.
The Individual Enrollment Period begins with the month in which the individual receives notice from SSA that his/her entitlement to Disability and Medicare will end solely due to SGA. The enrollment period ends 7 months later.
There will also be a General Enrollment Period each year from January 1 - March 31.
Approval:
If all eligibility factors have been met, and the case is approved, the Caseworker will perform the following tasks:
For example, an individual applies for QDWI benefits on September 1 and the effective month of Medicare Part A is August. This individual's QDWI benefits could begin August 1. If, however, the individual has not reenrolled for Medicare Part A prior to making application, and his Medicare Part A entitlement will not be effective until October 1, QDWI benefits cannot be effective prior to October 1.
Send a memorandum to Employment and Income Support Section, P.O. Box 1437, Slot 1223, Little Rock, AR 72203, requesting activation of the Part A buy-in.
Denial and Withdrawal:
When denying the application, the Caseworker will:
For withdrawals only, a signed written statement must be obtained from the applicant stating that he/she wishes to withdraw the application.
QDWI reevaluations will be conducted annually. Since the cases are certified in closed status, DCO-75's will not be generated to the counties to inform them of reevaluations that are due. The Caseworker will manually issue DCO-75's to notify individuals of appointment dates.
The counties will receive a report monthly to identify active QDWI's. The report will list the Case Number, Case Name, Last Action Date and an Overdue column. An asterisk will be in the Overdue column for an individual if more than 12 months have lapsed since the last Action Date.
All eligibility factors will be redetermined. Completion of Form DCO-777 is necessary at each reevaluation. If the individual continues to be eligible, the Caseworker will send a memorandum to the Central Office-Employment and Income Support Section, P. O. Box 1437, Slot 1223, Little Rock, AR 72203, to request that the reevaluation date be updated. The case will remain in closed status.
When a change occurs that makes an individual ineligible for QDWI, the Caseworker will send a memorandum to the Central Office-Employment and Income Support Section, P. O. Box 1437, Slot 1223, Little Rock, AR 72203, to inactivate the case and stop payment of the Medicare Part A premium for the individual. A 10 day notice of closure will be issued by the county, unless advance notice is not required (Re. MS 3633).
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.