Medicare Programs
DSHS Home Page
 
Search     for:
DSHS Home    Acronyms    Revisions    WAC Number Index    Site Map    WCCC

Medicare Programs


Revised September 22, 2014



Purpose: There are several different programs designed to help clients pay for Medicare premiums, deductibles, and coinsurance.

WAC 182-517-0100Medicare savings programs--Monthly income standards.
WAC 182-517-0300Federal Medicare savings and state-funded Medicare buy-in programs.
WAC 182-517-0310Eligibility for federal Medicare savings and state-funded Medicare buy-in programs
WAC 182-517-0320Medicare savings and state-funded Medicare buy-in programs cover some client costs.

Medicare Buy-In Unit

*** As a result of implementation of the Affordable Care Act (ACA), this clarifying page may no longer be effective for medical coverage applications received on or after 10/01/2013. Please see the ACA Transition Plan for more information. Clients under 65 years of age who need to apply for medical coverage on or after 10/01/2013 should be referred to Washington Healthplanfinder. Applications for medical coverage for households where all members are 65 years of age and older should be referred to Washington Connection. ***

For assistance with Medicare premium payment questions only, contact the Medicare buy-In Unit at 1-800-562-3022 Ext: 16129.

(If you have an eligibility question or need assistance with an Administrative Hearing issue, please contact your regional medicaid eligibility policy representative at the Health Care Authority, Office of Medicaid, Medicare, Eligibility and Policy)


WAC 182-517-0100

WAC 182-517-0100

Effective November 21, 2011

WAC 182-517-0100 Medicare savings programs--Monthly income standards.

  1. The income standards for Medicare Savings Programs change each year based on the federal poverty level (FPL) published yearly by the federal government in the Federal Register at http://aspe.hhs.gov/poverty/index.shtml. The qualified Medicare beneficiary (QMB) program income standard is up to one hundred percent of the federal poverty level (FPL).

  2. The specified low-income Medicare beneficiary (SLMB) program income standard is over one hundred percent of FPL, but not more than one hundred twenty percent of FPL.

  3. The qualified individual (QI-1) program income standard is over one hundred percent of FPL, but not more than one hundred thirty-five percent of FPL.  

  1. The qualified disabled working individual (QDWI) program income standard is two hundred percent of FPL .

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-517-0300
WAC 182-517-0300

Effective July 1, 2012

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

  1. Federal Medicare savings and state-funded Medicare buy-in programs help clients pay some of the costs that Medicare does not cover under WAC 388-517-0320 (for program eligibility, see WAC 388-517-0310). The department offers the following Medicare savings programs to eligible clients:

    1. Qualified medicare beneficiary (QMB);

    2. Specified low-income medicare beneficiary (SLMB);

    3. Qualified individual (QI); and

    4. Qualified disabled working individual (QDWI).

  2. The department offers the state-funded Medicare buy-in program for clients who receive Medicaid but do not qualify for the federal Medicare savings programs.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

What is Medicare and Who Can Get Medicare?

  1. Medicare is a federal health insurance program administered by the Social Security Administration (SSA) and the Centers for Medicare and Medicaid Services (CMS). Medicare covers people who:

             a.  Have worked under the Social Security or Railroad Retirement systems (for more Railroad Retirement information see Worker Responsibilities, section 2) and:

                   i.   Are age 65 or older; or

                   ii.  Have been receiving Social Security or Railroad disability benefits for at least 24 months; or

               b.  Need continuing dialysis for permanent renal failure; or

               c.  Have received a kidney transplant within the last thirty-six months; or

               d.  Are receiving Supplemental Security Income (SSI) and;

                    i.  Are age 65 or older; and

                     ii.  Who meet the citizenship and alien status requirements in chapter 388-424 WAC.

               e.  A client can apply for medicare online at Social Security Administration's website:http://www.socialsecurity.gov/medicareonly

2.  The Medicare program includes four kinds of health insurance coverage:

      a.  Part A is hospital insurance; and

            i.  Is free for people who have worked, andhave earned the required number of work quarters, or have a spouse who has earned the required number of work quarters;

            ii. Part A is also available at a cost for Medicare entitled individuals who do not have the required number of work quarters for free Medicare Part A.

            iii.  Medicare entitlement dates are located in SOLQ on the SSA2 screen.  Part A is called “Health Insurance”.  ”Part A entitlements are also listed in aces.online on the BENDEX.

       b.  Part B is medical insurance (doctor’s visits); and

             i.  Everyone who enrolls in Part B must pay a monthly premium;

             ii.  Medicare entitlement dates are located in SOLQ on the SSA2 screen.  Part B is called “Supplemental Medical Insurance”.  Part B entitlements are also available in aces.online on the BENDEX. 

       c.  Part C is an optional way to get Medicare coverage;

             i.  Part C is called Medicare Advantage and means a managed care plan.

             ii.  Medicare beneficiaries that choose Medicare Advantage (Part C) must be entitled to Medicare Part A and Medicare Part B or they cannot enroll in a Part C plan.d

             iii.  Medicare Advantage (Part C) beneficiaries must pay a monthly premium in addition to Part A and Part B premiums when they enroll in a Part C plan.

                   A.  Several Part C plans doing business in this region do not charge a monthly premium.

                   B.  DSHS/HCA no longer pays Part C premiums.

        d.  Part D is Medicare’s prescription drug program. Part D benefits are available to all Medicare beneficiaries.  To be eligible for Part D the beneficiary must be enrolled in Part A or Part B Medicare;

             i.  The Centers for Medicaid and Medicare Services (CMS) automatically enrolls dual eligible (eligible for Medicaid and Medicare) and MSP clients into a Part D plan.

             ii.  Dual-eligible clients begin receiving most of their prescription drug benefits through Medicare and not Medicaid effective with dual eligibility status (CN or MN plus Medicare).

             iii.  Dual-eligible and MSP clients may change to a different Part D plan every month if they choose;

             iv.  The requirement to purchase drugs through a Medicare Part D plan begins as soon as Medicaid (HCA) is notified of Medicare eligibility;

                   A.  Medicare has contracted with Limited Income Net (Humana) to provide prescription drug coverage for Medicaid clients newly entitled to Medicare and not yet enrolled in a Part D plan.

                   B.  Pharmacies can bill the Limited Income Net (Humana) plan when a Medicaid client has not yet enrolled in a Part D plan.  Medicaid clients must show proof of Medicaid eligibility and Medicare entitlement to the pharmacist. A Medicaid award letter is sufficient proof of Medicaid and a Medicare card or letter from SSA stating the effective date of Medicare is sufficient proof of Medicare entitlement.

                   C.  The Limited Income Net (Humana) plan can be reached at 1-800-783-1307. 

             v.  Dual-eligible and MSP clients have copayment cost sharing for Part D covered drugs. 

             vi.  Institutionalized and Home & Community Service waivered clients are exempt from paying Part D copayments. If an HCBS waiver client is still being charged Part D copayments at their pharmacy, refer the client to contact CMS at (206) 615-2354.   For more information specific to long-term care clients, see  Medicare and Long-term Care  in the long-term care section of the manual.

             vii.  Medicaid continues to pay for some drugs that Medicare excluded under Medicare Part D rules.

             viii.  Medicaid clients receive a ProviderOne ID card that looks similar to a plastic credit card. Providers can use this card to determine what medical programs a client may be receiving in the ProviderOne system.


WAC 182-517-0310
WAC 182-517-0310

Effective July 1, 2012

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

  1. Persons eligible for any medicare savings programs (MSP) must: 

    1. Be entitled to or receiving medicare Part A. Qualified disabled working individuals (QDWI) clients must be under age sixty-five;

    2. Meet program income standards, see WAC 388-478-0085; and

    3. Have resources equal to or less than the medicare Part D low-income subsidy resource standard found at:  http://hrsa.dshs.wa.gov/Eligibility/PDF/StandardsChart909.pdf. MSP follow SSI categorically needy program rules for SSI related persons in chapter 388-475 WAC.

  2. MSP clients are entitled to a fair hearing when the department takes an adverse action such as denying or terminating MSP benefits.

  3. The department subtracts the allocations and deductions described under WAC 388-513-1380  from a long-term care client’s countable income and resources when determining MSP eligibility;

    1. Allocations to a spouse and/or dependent family member; and

    2. Client participation in cost of care.

  4. Medicaid eligibility may affect MSP eligibility, as follows:

    1. Qualified medicare beneficiaries (QMB) and specified low income beneficiaries (SLMB) clients can receive medicaid and still be eligible to receive QMB or SLMB benefits.

    2. Qualified individuals (QI-1) and qualified disabled working individuals (QDWI) clients who begin to receive medicaid are no longer eligible for QI-1 or QDWI benefits.

  5. Every year, when the federal poverty level changes;

    1. The department adjusts income standards for MSP and state funded medicare buy-in programs, see WAC 388-478-0085.

    2. The department begins to count the annual Social Security cost-of-living (COLA) increase on April 1st each year when determining eligibility for MSP and state funded medicaid buy-in programs.

  6. There is no income limit for the state-funded medicare buy-in program. The state funded medicare buy-in program is for clients who receive medicaid but do not qualify for the federal MSP.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

How Does Someone Apply or Recertify for Medicare Savings Programs (MSP)?

  1. A person applying for MSP can use the DSHS 14-001, or the DSHS 13-691 application form.  MSP applications can be initiated at SSA and sent electronically by a daily SSA/LIS interface file to ACES for auto-screening into ACES as a pending application.  See Applications for Assistance - Special Situations or the BE ACES release document for more information.
  2. A person reapplying for MSP can use any of the DSHS forms, 14-001, the 13-691, or the 14-078.
  3. An applicant can apply or reapply by mail or in person.  
  4. A face-to-face interview is not required.
  5. Clients receiving SSI (S01) and MSP do not need to reapply or be recertified unless their SSI benefits end.
  6. Applicants with other medical insurance coverage need to complete a DSHS Third Party Liability 14-194 form. For more information refer to the TPL Chapter. 
  7. See the Medicare Savings Programs chart  for a useful overview of the programs discussed in this section. 

 

How a client is determined eligible for a Medicare Savings Program

  1. Eligibility for an MSP follows SSI-related categorically-needy (CN) rules described in Chapter 182-512 WAC.   For a single client, net countable income is compared to the income standards described in WAC 182-517-0100.  
  2. When a married person applies for an MSP, eligibility is determined using the 2-person standard when both applicants are applying for and entitled to Medicare.    When only one person in the couple is applying for an MSP, eligibility is determined as follows:
    1. Compare the income of the non-applying spouse (NAS) (after allowable deductions to children in the household, if any) to one half of the federal benefit rate (FBR).  If the countable income of the non-applying spouse is equal to or less than ½ FBR, then no income is allocated to the MSP applicant and only the applicant’s income is compared to the ONE-person MSP standard.
    2. If the countable income of the non-applying spouse is greater than ½ FBR, then their countable income is allocated to the MSP applicant.   The applicant is then allowed the standard $20 exclusion and a deduction of $65 plus ½ of any earned income.   The remaining amount is then compared to the TWO-person MSP standard. 

See the MSP Eligibility Chart for more information.

 

How Do I Recognize Medicare Part A Entitlement?

  1. Obtain proof of Medicare Part A entitlement from the client. You can use the following:
    1. Medicare card;
    2. Medicare award letter, if available;
    3. State On-Line Query (SOLQ) screen SSA2 and BENDEX (aces.online), except for Railroad Retirement Board beneficiaries. 
    4. The SSA2 screen shows Medicare Part A (Health Insurance) and Part B entitlement (Supplemental medical insurance).
    5. Contact the Railroad Retirement Board at 1-800-808-0722 (see Worker Responsibilities, section 2).
  2. For MSP and State-funded Buy-In, clients need to be:
    1. Entitled to Medicare Part A but do not have to be receiving or enrolled in Part A at the application for benefits; and
    2. Entitled to Medicare Part A when asking for retroactive certification for each of the retroactive months.

 

What is the Program Priority for Medicare Savings Programs?

  1. Qualified Medicare Beneficiary not eligible for a Medicaid program (QMB only)
    1. The ACES medical coverage group for QMB is S03.
    2. The income standard for a QMB is 100% FPL.
  2. Qualified Medicare Beneficiary eligible for a Medicaid program (QMB dual eligible)
    1. The ACES medical coverage group for QMB is S03 with the other Medicaid program.
    2. QMB dual eligible clients are screened in ACES on medical coverage group S03 and a Medicaid program; for example, S03 and S02.
  3. Specified Low-Income Medicare Beneficiary not eligible for a Medicaid coverage (SLMB only)
    1. The ACES medical coverage group is S05.
    2. The income standard for SLMB is 120% of FPL.
  4. Specified Low-Income Medicare beneficiary eligible for a Medicaid program (SLMB dual)
    1. The ACES medical coverage group is S05. The Medicaid programs medical coverage group will vary depending on the client’s eligibility.
    2. SLMB dual eligible clients are screened into ACES on medical coverage group S05 and a Medicaid program; for example, S05 and S02.
  5. Qualifying Individuals (QI-1)
    1. The ACES medical coverage group is S06.
    2. The income standard for QI-1 is 135% of FPL.
  6. Qualified Disabled Working Individual (QDWI)
    1. The ACES medical coverage group is S04.  
    2. The income standard for QDWI is 200% of FPL.
    3. Individuals must be employed to qualify.
  7. State-funded Buy-In
    1. There is no ACES coverage group for these clients.
    2. Any client who is eligible for medicaid and there is no MSP open, is eligible for the state-funded buy-in program. 

 

How Does the Buy-In Process Work?

  1. Staff determines Medicare Savings Program eligibility according to MSP WAC and SSI related eligibility rules.
  2. ProviderOne runs a search application every month to find Medicaid and MSP clients eligible for Medicare premium payment/buy-in. This happens the last week in the month. This process identifies clients who meet the buy-in criteria. The client data is sent to the Centers for Medicare and Medicaid (CMS).
  3. CMS compares the state’s data against their own to match for name, date of birth, sex, and HIC number.
  4. CMS forwards the matched data to the SSA payment centers to issue Part B refunds to beneficiaries and to update SSA record.
  5. The Medicare Buy-In Unit (MBU) may send email to CSO and HCS staff requesting corrective actions such as SO3 screening, or other actions.
  6. If after 60-90 days, the client is being billed for Part B premiums or their Part B premiums are still being deducted from their benefit checks, tell the client to contact you or the buy-in unit at 800-562-3022 ext 16129.

What about MSP and Spenddown Programs?

  1. A client pending spenddown may be eligible for MSP if their income and resources meet program requirements.
  2. A client may receive any of the MSP when spenddown is pending. Only QMB and SLMB may be open concurrent with another medical program. 
  3. When a client pending spenddown receives MSP benefits under MSP QI-1 or QDWI, and is later certified for a CN or MN medical program, ACES will prompt the worker to close the QI-1 or QDWI. The client can be reopened for the balance of the original QI-1 or QDWI certification period if any, when spenddown certification ends.

EXAMPLE

A person pending spenddown is opened on MSP QI-1 based on their income. The client meets spenddown and is no longer eligible for QI-1 when receiving Medicaid.  When spenddown certification ends, the client is re-opened (a new application is not needed) on QI-1 for any remaining months of the original QI-1 certification.


What about HWD/SO8 and MSP or state-funded buy-in?

  1. To be eligible for the federal Medicare Savings Programs (MSP), HWD clients must meet all the MSP criteria in the above MSP WACs, specifically income and resource requirements.
  2. When the HWD client loses eligibility for free Part A but meets eligibility criteria for QDWI, the state can pay Part A premiums but may not pay the client’s Part B premium.  To do this the client would have to be closed from HWD and enrolled in QDWI. 
  3. If the HWD client who loses eligibility for free Part A self-pays their Part A premium, the state may pay Part B premiums through the state-funded buy-in program as long as the client continues to self-pay Part A premiums.  The client will also be eligible for continued Medicaid (HWD).
  4. If the client stops self-paying their Part A premium the state can no longer pay the client’s Part B premium.

The state may not pay both Part A and Part B premiums for those HWD clients who have lost free Part A entitlement.


WORKER RESPONSIBILITIES

  1. Refer clients with Medicare questions to Medicare at 1-800- Medicare (1-800-633-4227) or TTY/TDD 1-877-486-2048.
  2. Refer clients with questions about Railroad Retirement (RRB) benefits to the Railroad Retirement Board at 1-800-808-0722.
  3. Railroad Retirement Medicare entitlement is NOT in SOLQ.  The client can present a Red, White and Blue Medicare entitlement card or RRB approval or award letter that shows the client's or dependent's Medicare coverage.  RRB award letters do not provide entitlement dates for Part A and Part B.  The RRB Red, White and Blue cards do provide Medicare entitlement dates.
    1. Workers should call 1-877-772-5772 to request RRB Medicare entitlement dates.
    2. Update TPL screens as you would when information about Medicare entitlement is available in SOLQ.
    3. Approve the appropriate Medicare Savings Program when a client or dependent of a RRB client has RRB Medicare coverage.
  4. Refer client questions about the Medicare Prescription Drug Program (Medicare Part D) or specific drug plans to:
    1. Medicare 1-800-Medicare; or
    2. SHIBA HelpLine 1-800-562-6900.
  5. Refer client questions about Extra Help Paying for Medicare Prescription Drug Costs to:
    1. Social Security Administration (SSA) at 1-800-772-1213; or
    2. SHIBA HelpLine 1-800-562-6900.
  6. Processing MSP cases in ACES includes adding and/or updating the TPL screens unless ProviderOne has already updated the ACES TPL screens.
  7. Medicare and Long-Term Care.  This section provides more detailed information about Medicare Part D and post-eligibility determinations. 

WAC 182-517-0320
WAC 182-517-0320

Effective July 1, 2012

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

  1. For qualified Medicare beneficiary (QMB) clients, the agency pays medicare Part A premiums (if any) and medicare Part B premiums the first of the month following the month the QMB eligibility is determined. The agency pays, in accordance with WAC 182-502-0110, medicare coinsurance, deductibles, and copayments for medicare Part A, Part B and medicare advantage Part C.   
  2. For specified low-income Medicare beneficiary (SLMB) clients, the agency pays Medicare Part B premiums effective up to three months prior to the certification period if eligible for those months. No other payments are made for SLMBs.  For clients eligible for both SLMB and medicaid, the agency pays medicare Part B premiums and other medical costs in accordance with WAC 182-502-0110.
  3. For qualified individual (QI-1) clients, the agency pays Medicare Part B premiums effective up to three months prior to the certification period if eligible for those months unless:
    1. The client receives Medicaid categorically need (CN) or medically needy (MN) benefits; and/or
    2. The agency’s annual federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
  4. For qualified disabled working individual (QDWI) clients, the agency pays Medicare Part A premiums effective up to three months prior to the certification period if eligible for those months. The agency stops paying Medicare Part A premiums if the client begins to receive CN or MN Medicaid.
  5. For state-funded Medicare buy-in program clients, the agency pays, in accordance with WAC 182-502-0110, medicare Part B premiums.  Cost sharing for medicare deductibles, copayments and coinsurance is paid by the categorically needy (CN) or medically needy (MN) medicaid program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

What do the Medicare Savings Programs (MSP) and Medicaid offer Medicare Beneficiaries?

  1. The MSP pays some out-of-pocket Medicare expenses for Medicare beneficiaries who meet the MSP income and asset tests. For example and depending on the category of MSP eligibility, MSP can pay: 
    1. Part A and Part B premiums; and
    2. Deductibles, co-insurance, and co-payments for Medicare Parts A, B, and C.
  2. The state notifies Medicare every month via an electronic interface about clients with both Medicaid and Medicare. Medicare automatically assigns Medicaid clients with Medicare and/or MSP to a Medicare Part D plan. Medicare notifies these clients by mail about their Part D plan.

 

What expenses are not paid by the Medicare Savings Programs?   

The medicare savings programs do not pay for the following expenses:

  1. Medicare Part D premiums
  2. Medicare Part D prescription drug co-payments 
  3. Medigap policies 
  4. Medicare Part C premiums 
  5. Expenses incurred with a provider who is not contracted with medicaid.

 


ACES PROCEDURES

See Medicare Cost Sharing

Modification Date: September 22, 2014