Medicare, Buy-In, QMB, SLMB and QI-1. April 6, 2005. Medicare ?. What is Medicare Part A?
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Medicare, Buy-In, QMB, SLMB and QI-1
April 6, 2005
What is Medicare Part A?
Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.
Most people don’t have to pay a monthly payment, called a premium for Part A. This is because they or a spouse paid Medicare taxes while working.
What is Medicare Part B?
Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient care. It also covers some other medical services that part a doesn’t cover, such as some of the services of physical and occupational therapist, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
You pay the Medicare part B premium each month ($78.20 in 2005). This amount could be higher if you didn’t sign up for Part B when you first became eligible.
You may also pay a $110.00 Part B deductible each year before Medicare starts to pay its share.
Part B Premium Payment Program
What is Part B Buy In?
Buy-In refers to an agreement between the State and Federal governments in which the State uses Medi-Cal funds to pay the monthly Part B health coverage premiums for certain Medi-Cal recipients who are also eligible for Medicare. Although the eligibility requirements for Medi-Cal and Medicare are different, most Public Assistance (PA) and Medically Needy (MN) qualified persons, individuals 65 years of age or older, and blind or disabled individuals are eligible for the Medicare Buy-In Program.
California pays Part B premiums under a Buy-In agreement with the Health Care Financing Administration (HCFA). The benefit to the State in enrolling individuals in the Medicare Part B Buy-In Program is to pass along certain expenses to the Medicare Program, which would otherwise have to be paid by the Medi-Cal Program. All Medi-Cal recipients eligible for Medicare Part B coverage are required to participate in the Medicare Buy-In Program in accordance with Section 50777 of Title 22 of the California Code of Regulations.
Part B Premium and Deductible
The Part B Premium for 2005 is $78.20 per month per beneficiary. The premium amount may increase in January of each year as specified by the Secretary of Health and Human Services. In addition to the Part B premium, the State also pays the annual Part B deductible of $110.00 effective January 2005.
How isBuy-In Funded?
Under the Medicare Buy-In Program, the State uses Medi-Cal funds to pay the monthly Medicare Part B health coverage premiums for qualifying Medi-Cal recipients. After the State makes this premium payment, Medicare pays eighty percent (80%) of the reasonable costs of Medicare Part B covered services.
When Does Part B Coverage Begin
Coverage begins the third month after the individual’s eligibility for Medi-Cal is approved, providing the individual is eligible for Part B coverage.
Buy-In determination can be no earlier than the month of application and may be later.
Example:1. Applied for Medi-Cal April 2001
2. Approval DateMay 2001
3. Medi-Cal Effective Date January 2001 (Retro)
4. Buy-In Effective DateJuly 2001
A client who is eligible for Medicare Part B and is a Medi-Cal recipient is automatically eligible to buy-in. If a client requests discontinuance of the Medi-Cal Program, please inform them that the Medicare Premium will be deducted from their Social Security check. 2005 Premium is $78.20.
ISAWS will assign a Secondary Aid Code (80) for eligible members.
Note: These steps are for an existing case.
Specified Low-Income Medicare Beneficiary
What is SLMB?
The Specified Low-Income Medicare Beneficiary (SLMB) Program was established under Public Law 101-508. A SLMB must be entitled to Medicare Part A, have no more than twice Medi-Cal's property limit, ($4,000 for one person, $6,000 for a couple); have income below 120% of the federal poverty level (FPL) and be a citizen or alien who would be eligible for full Medi-Cal benefits.
A Specified Low-Income Medicare Beneficiary (SLMB) is ineligible as a Qualified Medicare Beneficiary (QMB) solely due to excess income.
The SLMB Program is limited to the payment of the Medicare Part B premium. It does not pay the Medicare Part A premium or the Part B deductibles or coinsurance. The SLMB's Medicare Part B premium will be purchased under the State Buy-In process.
A SLMB must be entitled to Part A Medicare hospital insurance benefits, meet the qualifying income level and meet the qualifying resource limit. The period of eligibility shall include the first month eligibility is approved, and may include three months of retroactive benefits from the month of application. If eligibility exists, the CDHS shall pay Medicare Part B premiums.
SLMB Aid code is 8C and can be retroactive for 3 months.
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