WSR 07-11-135

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 22, 2007, 9:32 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 05-17-137.

Title of Rule and Other Identifying Information: WAC 388-517-0310 Eligibility for federal medicare savings and state-funded Medicare buy-in programs and 388-517-0320 Medicare savings and state-funded Medicare buy-in programs cover some client costs.

Hearing Location(s): Blake Office Park East, Rose Room

4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on June 26, 2007, at 10:00 a.m.

Date of Intended Adoption: Not earlier than June 27, 2007.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail schilse@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on June 26, 2007.

Assistance for Persons with Disabilities: Contact Stephanie Schiller by June 19, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is amending these rules to be consistent with federal rules with regard to copayments, policies, and program eligibility. This rule change is necessary to comply with federal program rules and to achieve clear and concise WAC. These rules are consistent with requirements in the Medicaid state plan.

Reasons Supporting Proposal: Continuation of federal financial participation.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.

Statute Being Implemented: 42 U.S.C., Section 1396a.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Carole McRae, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1250.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule-making action does not affect small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. Per RCW 34.05.328 (5)[(b)](vii), client eligibility rules for medical assistance programs are exempt from the cost-benefit analysis requirement of RCW 34.05.328.

May 15, 2007

Stephanie E. Schiller

Rules Coordinator

3872.2
AMENDATORY SECTION(Amending WSR 05-14-125, filed 7/1/05, effective 8/1/05)

WAC 388-517-0310   Eligibility for federal medicare savings and state-funded medicare buy-in programs.   (1) Persons eligible for any medicare savings programs (MSP) must:

(a) Be eligible for or receiving medicare Part A. Qualified disabled working individuals (QDWI) clients must be under age sixty-five;

(b) Meet program income standards, see WAC 388-478-0085; and

(c) Have resources at or below twice the resource standards for SSI and SSI related programs, see WAC ((388-478-0085(6))) 388-478-0080(4).

(2) MSP follow categorically needy program rules for SSI related ((rules)) individuals in chapter 388-475 WAC.

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

(4) 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:

(a) Allocations to a spouse and/or dependent family member; and

(b) Client participation in cost of care.

(5) Medicaid eligibility may affect MSP eligibility, as follows:

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

(b) 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.

(6) Every year, when the federal poverty level changes:

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

(b) 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.

(7) 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.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, 388-517-0310, filed 7/1/05, effective 8/1/05.]


AMENDATORY SECTION(Amending WSR 05-14-125, filed 7/1/05, effective 8/1/05)

WAC 388-517-0320   Medicare savings and state-funded medicare buy-in programs cover some client costs.   (1) For qualified medicare beneficiary (QMB) clients, the department pays:

(a) ((Pays)) Medicare Part A premiums (if any);

(b) ((Pays)) Medicare Part B premiums;

(c) ((Pays all)) Coinsurance, deductibles ((as described in subsection (6) of this section;

(d) May pay Medicare Advantage Part C premiums, if cost effective, for those clients already enrolled in Medicare Advantage Part C at the time of application for Medicare Advantage Part C premium payment. (The department does not select a Medicare Advantage Part C plan for QMB clients);

(e) Pays all coinsurance deductibles and co-payments for QMB-eligible clients enrolled in Medicare Advantage Part C as described in subsection (6) of this section; and

(f) Pays QMB premiums the first of the month following the month that QMB eligibility is determined)), and copayments for medicare Part A, Part B, and medicare advantage Part C with the following conditions:

(i) Only the Part A and Part B deductible, coinsurance, and copayments up to the medicare or medicaid allowed amount, whichever is less, if the service is covered by medicare and medicaid.

(ii) Only the deductible, coinsurance, and copayments up to the medicare allowed amount if the service is covered only by medicare.

(d) Copayments for QMB-eligible clients enrolled in medicare advantage Part C up to the medicare or medicaid allowed amount whichever is less.

(e) QMB Part A and/or Part B premiums the first of the month following the month the QMB eligibility is determined.

(2) For specified low-income medicare beneficiary (SLMB) clients, the department 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.

(3) For qualified individual (QI-1) clients, the department pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months unless:

(a) The client receives medicaid categorically needy (CN) or medically needy (MN) benefits; and/or

(b) The department's annual federal funding allotment is spent. The department resumes QI-1 benefit payments the beginning of the next calendar year.

(4) For qualified disabled working individual (QDWI) clients, the department pays medicare Part A premiums effective up to three months prior to the certification period if eligible for those months. The department 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 department pays ((Medicare)):

(a) Medicare Part B premiums; and

(b) Only the Part A and B co-insurance, deductibles, and co-payments ((described in subsection (6) of this section)) up to the medicare or medicaid allowed amount, whichever is less, if the service is covered by medicare and medicaid.

(6) For the dual-eligible client, the department ((limits payments for certain services, provided to Medicare savings and state-funded Medicare buy-in clients,)) pays as follows:

(a) If the ((Medicaid payment rate is higher than the amount paid by Medicare, the department pays only the cost-sharing liability of the Medicare co-insurance charge)) service is covered by medicare and medicaid, medicaid pays only the deductible, and coinsurance up to the medicare or medicaid allowed amount, whichever is less; and

(b) ((For Medicaid clients who are entitled to Medicare Part A and/or Medicare Part B (referred to as "dual eligible" clients:

(i) The department pays the Medicare or Medicaid payment rate, whichever is less, for services covered by both Medicare and Medicaid; and

(ii) The department pays the Medicare deductibles and co-insurance services only covered by Medicare)) Copayments for medicare advantage Part C up to the medicare or medicaid allowed copayment amount, whichever is less;

(c) If no medicaid rate exists, the department will deny payment unless the client is also QMB then refer to section (1) above.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, 388-517-0320, filed 7/1/05, effective 8/1/05.]

Washington State Code Reviser's Office