PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Purpose: The Medicare savings program known as qualified individual 2 has been removed from WAC due to a change in federal law, and the WAC has been revised to make it clearer and more concise by breaking it out into three smaller WAC sections, adopting new sections WAC 388-517-0310 and 388-517-0320.
Citation of Existing Rules Affected by this Order: Amending WAC 388-517-0300.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530.
Other Authority: 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924).
Adopted under notice filed as WSR 05-11-076 on May 17, 2005.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.
Date Adopted: June 29, 2005
Andy Fernando, Manager
Rules and Policies Assistance Unit
3517.5(1) The department determines a person's eligibility in the following order:
(a) The qualified medicare beneficiary (QMB) program;
(b) The specified low-income medicare beneficiary (SLMB) program;
(c) The qualified individual (QI-1) program, formerly known as the expanded special low income Medicare beneficiary (ESLMB) program;
(d) The qualified disabled working individual (QDWI) program;
(e) The qualified individual (QI-2) program, formerly known as the qualified individual (QI) program;
(f) The state-funded buy-in program, formerly known as the Medicare buy-in program.
(2) In order to be eligible for any of these programs, a person must:
(a) Be eligible or receiving Medicare Part A; and
(b) For the QDWI program only, be under the age of sixty-five; and
(c) Have nonexcluded resources at or below the resource standard, see WAC 388-478-0085(6).
(3) A person must also meet the income standards as follows:
(a) For the QMB program, see WAC 388-478-0085(1);
(b) For the SLMB program, see WAC 388-478-0085(2);
(c) For the QI-1 program, see WAC 388-478-0085(3);
(d) For the QDWI program, see WAC 388-478-0085(4);
(e) For the QI-2 program, see WAC 388-478-0085(5); and
(f) For the state-paid buy-in program, there is no maximum income limit as long as the person receives services under either categorically needy (CN) or medically needy (MN) programs.
(4) When determining an LTC client's eligibility for Medicare savings programs, the department considers countable income and resources left after the following are deducted:
(a) Allocations to a spouse and/or dependent family members; and
(b) The client's participation in the cost of care.
Refer to chapter 388-513 WAC for the LTC rules.
(5) The department adjusts income standards for Medicare savings programs on April 1st of each year, see WAC 388-478-0085. The department also applies the annual Social Security cost-of-living adjustment (COLA) for these programs on April 1st of each year. Therefore, the annual COLA does not effect the eligibility of either applicants or clients of Medicare savings programs until April 1st of each year.
(6) The department pays the following benefits for Medicare savings program clients:
(a) Under the QMB program: Medicare Part A if any, Part B premiums, coinsurance, deductibles as described in subsection (7) of this section, and medical expenses the client's Medicare managed care plan charges;
(b) Under the SLMB or QI-1 programs: Only Medicare Part B premiums (see the exception under subsection (11) of this section);
(c) Under the QDWI program: Only Medicare Part A premiums;
(d) Under the QI-2 program: Only a part of the client's Medicare Part B premiums. The Centers for Medicare and Medicaid (CMS) determine the amount which is paid. The department pays the client on an annual basis (see the exception under subsection (11) of this section); and
(e) Under the state-funded buy-in program: Medicare Part B premiums, coinsurance, deductibles as described in subsection (7) of this section, and medical expenses a client's Medicare managed care plan charges.
(7) The department has certain maximum payments for services provided to Medicare savings programs clients:
(a) Medicare co-insurance charges are paid only if the Medicaid payment rate is higher than the amount paid by Medicare, and within that limit, only the cost-sharing liability;
(b) Dual eligible clients are those who are eligible for QMB and SLMB programs and another Medicaid program. For dual eligibles, the department's maximum payment is:
(i) for covered services, the Medicaid or the Medicare payment rate whichever is lower; and
(ii) for services only covered by Medicare, the Medicare deductibles and co-insurance is the maximum Medicaid payment.
(8) The department does authorize QMB, SLMB or state-funded buy-in programs for the client receiving categorically needy (CN) or medically needy (MN) programs. The state-funded buy-in program is only for a client receiving CN or MN medical coverage who is not eligible for the QMB or SLMB programs.
(9) The department does not authorize QI-1, QI-2, or QDWI programs for a client receiving CN or MN medical program benefits.
(10) The department does not authorize the QI-2 program for a client who is eligible for one of the other Medicare savings programs.
(11) When the department's annual allotment of federal funds for the QI-1 and QI-2 programs is exhausted, the department does not authorize benefits under the respective program for the remainder of that calendar year.
(12) For certification periods for the Medicare savings programs, refer to WAC 388-416-0035))(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).
(2) The department offers the following Medicare savings programs to eligible clients:
(a) Qualified medicare beneficiary (QMB);
(b) Specified low-income medicare beneficiary (SLMB);
(c) Qualified individual (QI-1); and
(d) Qualified disabled working individual (QDWI).
(3) 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.
[Statutory Authority: RCW 74.08.090, 74.09.530. 02-11-074, § 388-517-0300, filed 5/13/02, effective 6/13/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-517-0300, filed 7/31/98, effective 9/1/98. Formerly WAC 388-517-1710, 388-517-1730, 388-517-1750 and 388-517-1770.]
(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 resource standards, see WAC 388-478-0085(6).
(2) MSP follow SSI related rules 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.
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(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.
(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. 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 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. 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) Part B premiums; and
(b) Part A and B co-insurance, deductibles, and co-payments described in subsection (6) of this section.
(6) The department limits payments for certain services, provided to Medicare savings and state-funded Medicare buy-in clients, 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; 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.
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