Medicare Savings Program
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Medicare Savings Program


Revised December 31, 2012



Purpose:

Medicare Savings Programs (MSP)

Qualified Medicare Beneficiary (QMB) – S03

 

Special Low-Income Medicare Beneficiary (SLMB) – S05

 

Qualified Individual (QI-1) – S06

 

Qualified Disabled and Working Individual (QDWI) – S04

 


Qualified Medicare Beneficiary (QMB) – S03

  

What is the S03 medical program?

 

Who is eligible to receive S03 medical?

 

How long is the S03 certification period?

 

Who does ACES AUTO open a Medicare Savings Program (MSP) for?

 

What if the client is also applying for Long Term Care (LTC) medical?

 

How do I screen S03 medical?

 

How do I process a pending S03 AU?

 

How do I determine eligibility for a married couple when one or both clients receive SSI?

 

What if the client’s countable income exceeds 100% if the FPL?

 


 

What is the S03 medical program?

 

·         S03 medical is a Medicare Savings Program (MSP) that helps clients pay some of their Medicare costs such as: Medicare Part A & B premiums, co-insurance and deductibles.

 

·         See EAZ Manual – WAC 182-517-0320 Medicare savings and state-funded Medicare buy-in programs cover some client costs for additional information.

 

·          The Beneficiary and Earnings Data Exchange (BENDEX) interface is a source of Medicare Part A and Part B data. ACES automatically updates or creates the TPL1 for clients with Medicare Part A or Part B participation. ACES generates a user of record informational alert regarding updates.

Who is eligible to receive S03 medical?

 

·         A person who meets the criteria in the following WAC/EAZ Manual sections may be eligible for S03 Medical:

 

o    WAC 182-517-0300 Federal Medicare savings and state-funded Medicare buy-in programs.

 

o    WAC 182-517-0310 Eligibility for federal Medicare savings and state-funded Medicare buy-in programs.

 

o    WAC 182-517-0320 Medicare savings and state-funded Medicare buy-in programs cover some client costs.


NOTE:

A client eligible for SSI and Medicare is always eligible for S03 when the TPL1 screen is updated with an active Medicare Part A or Part B policy with an end date greater than the benefit month being processed or is blank.


     

How long is the S03 certification period?

 

·         The default certification period for an S03 AU is 12 months unless the client also receives SSI Categorically Needy medical (S01), then the S03 AU will not have a certification end date.

 

·         Eligibility for S03 begins the first of the month following the month eligible is determined for the program and the client is Medicare Part B eligible. The application month will be denied with Reason Code 279 - QMB Start Date.

 

·         See EAZ Manual WAC 182-504-0025 Medicare savings program certification periods.

 

Who does AUTO open a Medicare Savings Program (MSP) AU for? 

 

·         ACES auto opens S03:

 

o   For SSI recipients based on information received from Social Security Administration (SSA).

 

o   For SSI-related recipients on one of the programs listed below based on Third Party Liability (TPL) information received on the ProviderOne interface:

G03                 L02                 S02

G95                 L22                 S95

G99                 L95                 S99    

L99


NOTE:   If a client is pending on one of the medical coverage groups listed above, a Barcode tickle generates with the message “Client is Medicare Eligible (Date); Review for MSP”.



·         Alert 245 – AUTO-OPEN NOT POSSIBLE REVIEW FOR MEDICAID/MEDICARE ELIGIBILITY is sent to the user of record on cases where the system is unable to auto open because of a discrepancy in name, birth date or SSN.

 

·         Eligibility for QMB (Qualified Medicare Beneficiary Program) begins the first of the month following the month eligibility is determined for the program.

 

What if the client is also applying for Long Term Care (LTC) medical?

 

·         Finalize the LTC medical application before processing and finalizing the S03 AU.  Clients who are eligible for LTC medical are eligible for S03. See EAZ Manual – WAC 182-517-0310 Eligibility for federal Medicare savings and state-funded Medicare buy-in programs (4).

 

·         The income standard is higher for (LTC) medical programs so if you finalize the S03 prior to finalizing the (LTC) medical AU, the S03 could incorrectly trickle to S05/S06 or deny for Reason Code 301 – Exceeds Income Standards.

 

How do I screen S03 medical?

 

·         To screen an S03 AU, take the following steps:

 

1.    From the Welcome back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.

 

2.    On the Applicant page:

 

o    Enter the head of household’s Name, Residential and Mailing addresses.

 

¨        Using the Street Number, Dir Name, Type, City Dir, City and Zip, ACES will attempt to verify both the Residential and Mailing Addresses, in real time, through a United States Postal Services – USPS software program called Finalist.

 

o    If the applicant has a mailing address, click the box next to Mailing Address same as above to remove the checkmark and enter the applicant’s mailing address.

 

o    Click the Next button. The Address Validation page displays.

 

3.    On the Address Validation page:

 

o    Take any necessary steps to complete the address validation process. See Screening – Address Validation for additional information.

 

o    Click the Next button.

 

4.    On the Programs page:

 

o    Click the checkbox next to Medical.

 

o    In the Program Determination Criteria section, click the checkbox next to Medicare Part A Eligible.

 

o    Click the Next button, the Add Member – Search Criteria displays.

 

5.    Use the Add Member – Search Criteria and Add Member – Client Matches pages to enter the HOH and any other clients to the AU.

 

6.    Complete the screening process following the instructions in Screening – aces.online.

 

How do I process a pending S03 AU?

 

·         To process a pending S03 AU, take the following steps:

 

1.    On the AMEN screen, select Option O – Interview.

 

2.    On the STAT screen, complete the Finl Resp field as follows:

 

o    [PN] – Application for the applicant and an applying spouse.

 

o    [SP] – Ineligible Spouse for an ineligible or non-applying spouse.

 

o    [SC] – Child used to determine family size for any children (documented or undocumented).


NOTE:

It is important to code an ineligible spouse (SP) with the correct Financial Responsibility code on the STAT screen to issue benefits with the correct begin date. If an ineligible spouse is coded PN – Pending on the STAT screen the S03 will approve with an incorrect begin date instead of denying the application month with Reason Code 279 – QMB Start Date – For Administrative Use Only.


 

3.    On the DEM1 screen:

 

o    Enter the [appropriate valid value based on the client’s situation] in the Living Arrangement field.

 

o    Enter the [appropriate valid value] in the Marital Status field.

 

4.    On the DEM2 screen:

 

o    Enter the applicant’s [Dis/Incp/ESRD Type ] information in the Disability/Incapacity fields if applicable. See <F1> Help.

 

¨        If the S03 program eligibility is based on age, coding the Disability/Incapacity fields is optional.

 

o    Enter a [Y] in the Entitled Medicare field.

 

o    Press <F22> to access the TPL1 screen.

 

5.    On the TPL1 screen:

 

o    Enter [MEDA]  or [MEDB] in the Org field.

 

¨            Complete a second TPL1 screen if the client has both MEDA and MEDB.

o    Enter [Medicare Enrollment Date] in the Policy Effective Dates From field.

 

o    Enter [Number on Medicare Card] in the Policy Number field.

 


NOTE:

Effective 01/01/05, EAZ Manual WAC 182-512-0010 Supplemental Security Income (SSI) standards was modified (Revision 389) to eliminate Area 1 and Area 2 standards, there is now only one standard instead of two.


7.    After committing the interview data, follow the instructions in Process Application Month chapter for all pending months.

 

8.    After all pending months have been process; follow the instructions in the Finalize Application chapter to complete the S03 eligibility determination.

 

How do I determine eligibility for a married couple when one or both clients receive SSI?

 

·         When a S03 AU contains a married couple who are both entitled to Medicare with income type [SI] – Supplemental Security Income (SSI) Payment entered on the UNER screen, both are S03 eligible.

 

·         When an S03 AU contains a married couple who are both entitled to Medicare but only one is receiving [SI] income and the other is receiving [SS] Social Security:

 

o    Clients with SSI income will be approved for S03.

 

o    Clients with SSA income will be approved for S03 when their income and resources are below the S03 standard (based on the number of persons in the AU without SSI income).

 

o    Clients with SSA income who have income or resources exceeding the S03 standard will be closed or denied for the appropriate Reason Code 301 – Exceeds Income Standard or 401 – Over Resources.

 

o    The denied client should then be screened on their own AU to determine their eligibility for either S05 (Special Low-Income Medicare Beneficiary – SLMB)  or S06 (Qualified Individual – QI-1)  medical coverage. In this situation, code the SSI spouse with a Financial Responsibility code of [NM] – Non-Member on the non-SSI client’s AU. See How do I screen S03 medical?

 

·         If the head of household (HOH) has income or resources exceeding the S03 standard, but the AU contains another member who is S03 eligible, the HOH’s Financial Responsibility code will flip to [NM], with the appropriate reason code.

 

What if the client’s countable income exceeds 100% of the FPL?

 

·         The S03 trickles to the S05 medical program when the countable income is greater than 100% but not more than 120% of the Federal Poverty Level (FPL).

 

·         The S03 trickles to the S06 medical program when the countable income is greater than 120% but not more than 135% of the FPL.

 

o    Clients who are receiving coverage under another CN or MN program are not eligible to receive S06 coverage. See Who is eligible to receive S06 Medical?

 

·         See EAZ Manual – WAC 182-517-0100 Medicare savings programs – Monthly income standards.

 


Special Low-Income Medicare Beneficiary (SLMB) – S05

What is the S05 medical program?

 

Who is eligible to receive S05 medical?

 

How long is the S05 certification period?

 

How do I screen S05 medical?

 

How do I process a pending S05 AU?

 

What if the client’s countable income exceeds 120% of the FPL?

 


What is the S05 medical program?

 

·         The S05 medical is a Medicare Savings Program that pays Medicare Part B premiums for qualified clients.

 

·         See EAZ Manual – Medicare Programs for additional information.

 

Who is eligible to receive S05 medical?

 

·         A person who meets the criteria in the following WAC/EAZ Manual sections may be eligible for S05 Medical:

 

o    Is eligible for or receiving Medicare;

 

o    Has countable income greater than 100% but not more than 120% of the FPL and countable resources at or below the resource standards. See EAZ Manual – WAC 182-517-0100 Medicare savings programs—Monthly income standards.

 

How long is the S05 certification period?

 

·         S05 Medical is certified for 12 months.

 

·         Eligibility for S05 begins the first of the month the client becomes eligible for Part B coverage.

 

·         See EAZ Manual – WAC 182-504-0025 Medicare savings program certification periods.

 

How do I screen S05 medical?

 

·         An S05 AU is initially screened in as an S03 AU following the instructions in How do I screen S03 Medical?

 

How do I process a pending S05 AU?

 

·         Follow the S03 processing steps. See How do I process a pending S03 AU?

 

·         If eligible, the S03 AU trickles to S05 Medical when the AU is finalized.

 

What if the client’s countable income exceeds 120% of the FPL?

 

·         If the client’s countable income exceeds 120% of the FPL, the pending S03 trickles to the S06 (Qualified Individual QI-1) Medical program if the client’s countable income is greater than 120% but not more than 135% of the Federal Poverty Level (FPL) and:

 

o    Countable resources are at or below the Medicare Savings Program Resources found at http://hrsa.dshs.wa.gov/Eligibility/PDF/IncomeSTANDARDSchart.pdf.

 

o    Is not receiving Categorically Needy (CN) or Medically Needy (MN) medical coverage.

 

o    See EAZ Manual – WAC 182-517-0300 Federal Medicare savings and state-funded Medicare buy-in programs.

 

 


Qualified Individual (QI-1) – S06

What is the S06 medical program?

 

Who is eligible to receive S06 medical?

 

How long is the S06 certification period?

 

How do I screen S06 medical?

 

How do I process a pending S06 AU?

 

What if the client is active on S06 medical and applies for CN or MN medical?

 

How do I close the S06 medical when opening CN or MN medical?

 


 

What is the S06 medical program?

 

·         The S06 medical is a Medicare Savings Program that pays client’s Medicare Part B premiums.

 

·         See EAZ Manual – WAC 182-517-0300 Federal Medicare savings and state-funded Medicare buy-in programs for additional information.

 

Who is eligible to receive S06 medical?

 

·         A person meeting the following conditions is eligible to receive S06 Medical:

 

o    Is eligible for or receiving Medicare.

 

o    Has countable income greater than 120% but not more than 135% of the Federal Poverty Level (FPL) and countable resources at or below the resource standards. See EAZ Manual – WAC 182-517-0100 Medicare savings programs—Monthly income standards.

 

o    Is not receiving Categorically Needy (CN) or Medically Needy (MN) medical coverage under any other program.

 

How long is the S06 certification period?

 

·         The S06 medical program is certified from the month the AU is opened through the end of the current calendar year.

 

·         See EAZ Manual – WAC 182-504-0025 Medicare savings program certification periods.

 

How do I screen S06 medical?

 

·         An S06 AU is initially screened in as an S03 AU following the instructions in How do I screen S03 Medical?

 

How do I process a pending S06 AU?

 

1.    Follow the S03 processing steps. If eligible, the S03 AU trickles to S06 medical when finalized. See How do I process a pending S03 AU?

 

2.    On the TPL1 screen, in additional to entering Medicare Part A eligibility, enter the Medicare Part B eligibility as follows:

 

o    Enter [MEDB] in the Org field.

 

o    Enter the [Medicare Enrollment Date] in the Policy Effective Dates From field.

 

o    Enter [Number on Medicare Card] in the Policy Number field.

 

What if the client is active on S06 medical and applies for CN or MN medical?

 

·         A client cannot receive S06 when receiving CN or MN medical under any other program.  

 

·         You must close the S06 AU for all months that the client is requesting CN or MN medical. 

 

·         A client can be active on an S06 AU while on an AU in M (Pending Spenddown) status.

 

·         The S06 AU must be closed in all months for which S99 AU will be opened before authorizing the S99 to go from M to A status.

 

How do I close the S06 medical when opening CN or MN medical?   

 

·         You must manually close the S06 AU with a 500-level reason code in all historical months where a CN or MN medical program is opened for the client.  See User Entered Reason Codes for additional information on 500-level codes.

 


Qualified Disabled and Working Individual (QDWI) – S04

What is the S04 medical program?

 

Who is eligible to receive S04 medical?

 

How long is the S04 certification period?

 

How do I screen S04 medical?

 

How do I process a pending S04 AU?

 

What if the client is active on S04 medical and applies for CN or MN medical?  

 

How do I close the S04 medical when opening CN or MN medical?

 


 

What is the S04 medical program?

 

·         The S04 medical is a Medicare Savings Program that pays clients Medicare Part A premium only.

 

·         See EAZ Manual – WAC 182-517-0320 Medicare savings and state-funded Medicare buy-in programs cover some client cost for additional information.

 

Who is eligible to receive S04 medical? 

 

·         A person who meets the following criteria may be eligible to receive S04 Medical:

 

o    Is eligible for or receiving Medicare Part A.

 

o    Has countable income below 200% of the Federal Poverty Level (FPL) and countable resources at or below the resources standards. See EAZ Manual – WAC 182-517-0100 Medicare savings program – Monthly income standards.

 

o    Is not receiving Categorically Needy (CN) or Medically Needy (MN) medical coverage under any other programs.

 

o    Is under the age of 65.

 

How long is the S04 certification period?

 

·         S04 medical is certified for 12 months.

 

·         See EAZ Manual – WAC 182-504-0025 Medicare savings program certification periods.

 

How do I screen S04 medical?

 

·         To screen an S04 AU, take the following steps:

 

1.    From the Welcome back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.

 

2.    On the Applicant page:

 

o    Enter the head of household’s Name, Residential and Mailing addresses.

 

¨        Using the Street Number, Dir Name, Type, City Dir, City and Zip, ACES will attempt to verify both the Residential and Mailing Addresses, in real time, through a United States Postal Service – USPS software program called Finalist.

 

o    If the applicant has a mailing address, click the box next to Mailing Address same as above to remove the checkmark and enter the applicant’s mailing address.

 

o    Click the Next button. The Address Validation page displays.

 

3.    On the Address Validation page:

 

o    Take any necessary steps to complete the address validation process. See Screening – Address Validation for additional information.

 

o    Click the Next button.

 

4.    On the Programs page:

 

o    Enter a checkmark in the box next to Medical.

 

o    In the Program Determination Criteria section, click the checkbox next to Medicare Part A Eligible.

 

o    Click the Next button, the Add Member – Search Criteria displays.

 

5.    Use the Add Member – Search Criteria and Add Member – Client Matches pages to enter the HOH and any other clients to the AU.

 

6.    On the Finalize page, click the Specify Program button and the Finalize – Program Details page displays.

 

7.    On the Finalize – Program Details page:

 

o    Use the Program drop-down list to select Medical Assistance (MA).

 

o    Use the Medical Coverage Group drop-down list to select Qual Medical Disability Worker (S04).

 

o    Click the Next button to return to the Finalize page.

 

8.    Complete the screening process following the instructions in Screening – aces.online.

 

How do I process a pending S04 AU?

 

·         To process a pending S04 AU, take the following steps:

 

1.    On the AMEN screen, select Option O – Interview.

 

2.    On the STAT screen, complete the Finl Resp fields as follows:

 

o    [PN] – Applicant for applicant.

 

o    [SP] – Ineligible Spouse for an ineligible or non-applying spouse.

 

o    [SC] – Child used to determine family size for any children (documented or undocumented).

 

3.    On the DEM2 screen:

 

o    Enter the applicant’s disability information in the Disability/Incapacity fields if applicable. See <F1> Help.

 

o    Enter a [Y] in the Entitled Medicare field.

 

o    Press <F22> to access the TPL1 screen.

 

4.    On the TPL1 screen:

 

o    Enter [MEDA] in the Org field.

 

o    Enter [Medicare Enrollment Date] in the Policy Effective Dates From field.

 

o    Enter [Number on Medicare Card] in the Policy Number field.

 

5.    On the MISC screen for SSI related clients, enter a [1] or [2] in the ABD Area field.


NOTE:

Effective 01/01/05, EAZ Manual – WAC 182-512-0010 Supplemental Security Income (SSI) standards  was modified (Revision 389) to eliminate Area 1 and Area 2 standards, there is now only one standard instead of two.


6.    After committing the interview data, follow the instructions in Process Application Month chapter for all pending months.

 

7.    After all pending months have been processed; follow the instructions in Finalize Application to complete the S04 eligibility determination.

 

What if the client is active on S04 Medical and applies for CN or MN medical?

 

·         Client cannot be receiving CN or MN medical programs. See EAZ Manual – WAC 182-517-0300 Federal Medicare savings and state-funded Medicare buy-in programs. User must close the S04 medical for all months that client is requesting CN or MN medical.

 

How do I close the S04 medical when opening CN or MN medical?

 

·         You must manually close the S04 AU with a 500-level reason code in all historical months where a CN or MN medical program is opened for the client. The S04 medical must be closed before the CN or MN medical is finalized. See User Entered Reason Codes for additional information on 500-level codes.

Modification Date: December 31, 2012