WSR 02-07-114

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed March 20, 2002, 10:28 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 01-21-097.

Title of Rule: WAC 388-517-0300 Medicare savings programs.

Purpose: This rule is being amended to simplify language and to make it clearer.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090, 74.09.530.

Summary: This rule is being amended to simplify language and to make it clearer.

Reasons Supporting Proposal: Medical assistance clients will have an easier time understanding the rule.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Patricia Armstrong, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1725.

Name of Proponent: Department of Social and Health Services, governmental.

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

Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.

Proposal Changes the Following Existing Rules: It clarifies the language of the rule.

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

RCW 34.05.328 applies to this rule adoption. Although this rule meets the definition of a significant legislative rule, it is exempt under RCW 34.05.328 (5)(b)(vii) because it is a rule related to client medical eligibility.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on April 23, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by April 19, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., April 23, 2002.

Date of Intended Adoption: Not sooner than April 24, 2002.

March 14, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3052.1
AMENDATORY SECTION(Amending WSR 98-16-044, filed 7/31/98, effective 9/1/98)

WAC 388-517-0300   Medicare ((cost-sharing)) savings programs.   The Medicare savings programs help a client pay some of the costs that Medicare does not cover. When determining eligibility for these programs, the department follows the income and resource methodology of the Supplemental Security Income (SSI) program described in chapter 388-474 WAC. For a client receiving long-term care (LTC) services, refer to subsection (4) of this section.

(1) ((Clients eligible for the following programs receive benefits which help pay their Medicare coverage out-of-pocket costs:

(a) The qualified medicare beneficiary (QMB); and

(b) The special low-income medicare beneficiary (SLMB) and the expanded special low income Medicare beneficiary (ESLMB); and

(c) The Medicare buy-in program; and

(d) The qualified disabled working individual (QDWI); and

(e) The qualified individual (QI).

(2) To be eligible for any of these programs, clients must not have countable resources which exceed the resource standard in WAC 388-478-0085(6).

(3) Clients eligible for or receiving Medicare Part A and meeting the department's income standards have their Medicare Part A and Part B premiums, coinsurance, and deductibles paid for them under the QMB program. A person is income-eligible for QMB:

(a) When their countable income does not exceed the standard in WAC 388-478-0085(1); or

(b) When they meet the requirements of subsection (a) if their annual Social Security cost-of-living increase is not counted as income until April 1 of each year.

(4) Clients eligible for or receiving Medicare Part A benefits and meeting the department's income standards have their Part B Medicare premium paid for them under the SLMB or ESLMB program. In determining eligibility for SLMB or ESLMB, the annual Social Security cost-of-living increase is not counted as income until April 1 of each year. A person is income-eligible:

(a) For SLMB when their countable income is within the range specified in 388-478-0085(2);

(b) For ESLMB when:

(i) Their countable income is within the range specified in WAC 388-478-0085(3); and

(ii) They are not otherwise eligible for categorically needy (CN) or medically needy (MN) coverage; and

(iii) Until December 31st of each year or until the date that the annual allotment of federal funds is exhausted.

(5) Clients who are eligible for categorically needy (CN) or medically needy (MN) medical coverage, but not eligible for QMB or SLMB programs may be eligible for a third Medicare cost-sharing program. If they are eligible for or receiving Medicare Part A coverage, they receive the state-funded buy-in program. Under the buy-in program the department pays the following:

(a) Their Medicare Part A premiums, if any; and

(b) Their Medicare Part B premiums; and

(c) Their Medicare Part B coinsurance, and deductibles.

(6) Clients who are not eligible for QMB, SLMB or buy-in may be eligible for assistance with their Medicare out-of pocket costs. Clients who meet the following conditions have their Medicare Part A premium(s) paid for them under the QDWI program. A person is income-eligible for QDWI when:

(a) They are not otherwise eligible for CN or MN medical coverage; and

(b) They are eligible for Medicare Part A; and

(c) Their countable income does not exceed the standard in WAC 388-478-0085(4).

(7) Persons not eligible for any other Medicare cost-sharing program discussed in this section may receive compensation of one dollar and seven cents per month under the QI program. Total reimbursement is limited to the amount of money made available for this program from the federal government. The benefit is payable annually as partial reimbursement of their Medicare Part B premiums. A person is income-eligible for QI when:

(a) They are not otherwise eligible for CN or MN medical coverage; and

(b) Their countable income does not exceed the standard in WAC 388-478-0085(5))) 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.

[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.]

Washington State Code Reviser's Office