Preproposal statement of inquiry was filed as WSR 18-01-077.
Title of Rule and Other Identifying Information: WAC 182-517-0100 Federal medicare savings program.
Hearing Location(s): On March 12, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Conference Room 106B, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than March 13, 2019.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email email@example.com, fax 360-586-9727, by March 12, 2019.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email firstname.lastname@example.org, by March 8, 2019.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending this rule to create a second eligibility methodology based on household size for the qualified medicare beneficiary (QMB) program. This second eligibility method compares countable income to the federal poverty level based on family size, and the agency uses the eligibility methodology that provides clients with the highest level of coverage under the QMB program. If neither eligibility determination results in QMB coverage, the agency uses both methodology processes to determine if the client is eligible under any other medicare savings program.
Reasons Supporting Proposal: The new methodology in effect increases the income limit and will allow more households to become eligible for this benefit.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1408; Implementation and Enforcement: Mark Westenhaver, P.O. Box 45534, Olympia, WA 98504-5534, 360-725-1324.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule does not impose any costs on businesses.
(1) Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):
(a) The qualified medicare beneficiary (QMB) program;
(b) The specified low-income medicare beneficiary (SLMB) program;
(c) The qualified individual (QI-1) program; and
(d) The qualified disabled and working individuals (QDWI) program.
(2) Eligibility requirements.
(a) To be eligible for an MSP, a ((person))client must:
(i) Be entitled to medicare Part A; and
(ii) ((Be a U.S. citizen, U.S. national, qualified American Indian born abroad, or a qualified alien who satisfies or is exempt from the five-year bar under WAC 182-503-0535;
(iii) Not exceed the income limits in (d) of this subsection; and
))Meet the general eligibility requirements under WAC 182-503-0505.
(b) To be eligible for QDWI, a ((person))client must be under age sixty-five.
(c) ((Except as provided under (d) and (e) of this subsection, MSPs follow the income, resource, and deeming rules for SSI-related persons in chapter 182-512 WAC.
)) Income and resource limits.
(i) Income limits for all MSPs are found at https://www.hca.wa.gov/health-care-services-and-supports/program-administration/program-standard-income-and-resources.
(ii) If a ((person's))client's countable income is less than or equal to one hundred percent of the federal poverty level (FPL), the ((person may qualify))client is income eligible for the QMB program.
(((ii)))(iii) If a ((person's))client's countable income is over one hundred percent of the FPL, but does not exceed one hundred twenty percent of the FPL, the ((person may qualify))client is income eligible for the SLMB program.
(((iii)))(iv) If a ((person's))client's countable income is over one hundred twenty percent of the FPL, but does not exceed one hundred thirty-five percent of the FPL, the ((person may qualify))client is income eligible for the QI-1 program.
(((iv)))(v) If a ((person's))client's countable income is over one hundred thirty-five percent of the FPL, but does not exceed two hundred percent of the FPL, the ((person may qualify))client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.
(((e)))(vi) Resource limits.
(((i)))(A) The resource limit for the QMB, SLMB, and QI-1 programs ((may be found at http://www.hca.wa.gov/medicaid/eligibility/pages/standards.aspx.
))are found at https://www.hca.wa.gov/health-care-services-and-supports/program-standard-income-and-resources.
(B) The resource limit for the QDWI program is $4,000 for a single person and $6,000 for a married couple.
(((f)))(3) MSP income eligibility determinations.
(a) The agency has two methods for determining if a client is eligible for an MSP:
(i) The agency first determines if the client is eligible based on SSI-rated methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.
(ii) If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:
(A) The client;
(B) The client's spouse who lives with the client;
(C) The client's dependents who live with the client;
(D) The spouse's dependents who live with the spouse, if the spouse lives with the client; and
(E) Any unborn children of the client, or of the spouse if the spouse lives with the client.
(b) Under both eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining:
(i) Countable income and resources;
(ii) Availability of income and resources;
(iii) Allowable income deductions and exclusions; and
(iv) Deemed income from and allocated income to a nonapplying spouse and dependents.
(c) The agency uses the eligibility determination that provides the client with the highest level of coverage.
(i) If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.
(ii) If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.
(iii) If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.
(d) When calculating income under this section:
(i) The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
(ii) The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
(((g) Relationship of MSPs to other medicaid programs:
(i) A client eligible for another medicaid program may also receive QMB or SLMB coverage.
(ii) A client eligible for another medicaid program is not eligible for QI-1 or QDWI.
))(4) Covered costs.
(a) The QMB program pays:
(i) Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
(ii) Medicare coinsurance, copayments, and deductibles for Part A, Part B, and ((medicare advantage)) Part C, subject to the limitations in WAC 182-502-0110.
(b) If the client is eligible for both SLMB and another medicaid program:
(i) The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
(ii) The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and ((medicare advantage)) Part C subject to the limitations in WAC 182-502-0110.
(c) If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
(d) The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
(e) The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
(((4)))(5) MSP eligibility. Medicaid eligibility may affect MSP eligibility:
(a) QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
(b) QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
(((5) The FPL standards are found at: http://www.hca.wa.gov/medicaid/eligibility/pages/standards.aspx))
(6) Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.