Individuals Covered and Benefits 510-05-60-10

(Revised 3/1/20 ML #3575)

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IM 5419

IM 5419 Attachment

IM 5398

 

 

(N.D.A.C. Sections 75-02-02.1-22(1) and 75-02-02.1-10)

 

Individuals who are in receipt of SSI income and have Medicare Part B only will be determined eligible under the SSI Buy-In program. Individuals in receipt of SSI or SSI/SSA who have free Medicare Part A and Part B or have requested Medicaid to pay the Medicare Part A, will be processed under the Medicare Savings Program (MSP). An individual cannot be covered under SSI Buy-In and Medicare Savings Programs for the same time period.  The Medicare Savings program is the primary coverage for individuals who could qualify under both programs.  

 

If the individual loses SSI, they will need to be processed under the Medicare Savings Program. If eligible for QMB, the Medicare Part A will need to be added effective the month QMB eligibility starts.

 

Individuals over 65 who have no eligibility for SSI and are not eligible for free Medicare Part A can apply for Medicare Savings Program-Qualified Medicare Beneficiaries (QMB) to cover their Medicare premiums. The individual will need to apply for Medicare at Social Security. They will need to request Medicare Part A “conditional enrollment”. Conditional enrollment allows an individual to apply for premium-Medicare Part A at SSA on the condition he or she only wants the coverage if the state approves their QMB application. Medicare Part A start date will be the date the state can start paying the Medicare Part A.

 

Individuals eligible for Medicare Savings Program should not have their Medicare Savings Program coverage closed unless:

• They are over income or
• They are over assets or
• They are QI 1 and requesting Medicaid coverage.
  
  Note: An Individual cannot voluntarily terminate form the Premium Assistance Program.

Medicaid should not be automatically closed when an individual becomes eligible for QMB or SLMB. They may have services not covered under Medicare that can be paid by Medicaid.

Individuals must have Medicare Part A to be eligible under the following Medicare Savings Program coverages.

1. Qualified Medicare Beneficiaries (QMB) are entitled to payment of Medicare Part B. QMB can also pay Medicare Part A if the individual does not have free Part A. QMB eligible individuals are entitled only to Medicare cost sharing benefits beginning in the month following the month in which the eligibility determination is made (i.e. the application is received on March 29, eligibility is determined in April, the first month of QMB eligibility is May).

 

2. Specified Low-Income Medicare Beneficiaries (SLMB) are entitled only to payment of their Medicare Part B premium. Eligibility may be established for as many as three calendar months prior to the month in which the application was received or the date the Social Security Administration received the Low Income Subsidy application.

 

3. Qualifying Individuals (QI) are entitled only to payment of their Medicare Part B premium. Eligibility may be established for as many as three calendar months prior to the month in which the application was received or the date the Social Security Administration received the Low Income Subsidy application. A review of eligibility is required in December of each year to establish continued eligibility for the coming year.

Qualifying Individuals cannot be in receipt of any other Medicaid benefits for the same time period. A Qualifying Individual can request coverage for other Medicaid benefits, and eligibility can be established, only if the Qualifying Individual repays the Medicare cost sharing benefits received for the month(s) the other Medicaid benefits are needed. Medicaid benefits can only be authorized after the Medicare cost sharing benefits have been repaid.

When a recipient needs to repay Medicare cost sharing benefits, a check or money order can be made payable to the "North Dakota Department of Human Services" and collected by the county agency. The county agency must forward the check or money order to the Finance Division of the North Dakota Department of Human Services with a completed Medicaid credit form, SFN 828. A copy of the form can be found at 05-100-55.

 

Each year the federal government allocates a set amount of funds that can be used to provide coverage for Qualifying Individuals. In the event that the allocation for this state is exhausted in any given year, current recipients remain eligible, but additional persons cannot be added.

 

4. Qualified Disabled Working Individuals (QDWI) are entitled to payment of their Medicare Part A premium only. To be eligible the individual needs to be under 65 years old, working, has lost their premium-free Medicare Part A due to returning to work, are receiving medical assistance and meet the income and resource limits. (The eligibility determination for this group will temporarily be done by the Medicaid Eligibility Division of the North Dakota Department of Human Services.) Coverage for this group began July 1, 1990.