5101:1-39-01.1 Medicaid: low-income medicare assistance programs.

(A) This rule describes the procedure for determining eligibility for low-income medicare assistance programs.

(B) Qualified medicare beneficiary (QMB) medicaid.

(1) The QMB medicaid benefit package may include payments of the individual’s medicare part B premiums, the individual’s medicare part A premiums and/or the individual’s medicare deductibles, coinsurance, and copayments. Eligible individuals and couples:

(a) Are entitled to medicare part A hospital insurance benefits;

(b) Have income that does not exceed the applicable QMB medicaid income standard in accordance with rule 5101:1-39-21 of the Administrative Code;

(c) Have countable resources that do not exceed twice the standard under the supplemental security income (SSI) program: four thousand dollars for an individual or six thousand dollars for a couple;

(d) Meet non-financial medicaid eligibility requirements in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code; and,

(e) May also qualify for full medicaid benefits.

(2) Cost of living increases (COLAs) in Title II (social security) benefits are disregarded in determining the income of QMBs through March of each year. For QMBs medicaid income standards are updated effective April first of each year.

(3) Individuals entitled to enroll for medicare hospital insurance benefits under part A as qualified working disabled individuals (QWDI) as set forth in rule 5101:1-39-01.2 of the Administrative Code are not eligible for QMB medicaid.

(4) Unless otherwise noted in this rule, QMBs must meet the medicaid eligibility requirements as set forth in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(a) To determine QMB medicaid eligibility, the county department of job and family services (CDJFS) shall compare the individual’s/couple’s countable income to the QMB medicaid income standard as set forth in rule 5101:1-39-21 of the Administrative Code.

(i) “Countable income” is the total income (both earned and unearned) in cash or in kind, less the exemptions and disregards as outlined in rule 5101:1-39-18 of the Administrative Code; and income deemed to another in accordance with rule 5101:1-39-19 of the Administrative Code. After the deduction of each appropriate disregard, the subtotal is rounded down to the nearest whole dollar.

(ii) If countable income is equal to or less than the QMB medicaid income standard, the individual is eligible for QMB medicaid.

(iii) If countable income exceeds the QMB medicaid income standard, the individual is not eligible for QMB medicaid.

(b) Medicare beneficiaries cannot spend down excess income to meet the QMB medicaid income standard.

(5) The effective date of QMB medicaid eligibility is the first day of the month following the month the CDJFS makes the QMB medicaid eligibility determination. Retroactive coverage is not available for this covered group.

(6) Medicaid applicants entitled to medicare part A must have eligibility determined for medicaid and all categories of low-income medicare beneficiary medicaid. The individual may choose to accept both medicaid and QMB medicaid or to decline medicaid and/or QMB medicaid after they have been advised of the benefits of each category.

(a) When a medicare beneficiary is eligible for QMB medicaid but not eligible for medicaid, a notice shall be sent, approving QMB medicaid. The notice must also be accompanied by an JFS 07212 “Explanation of Qualified Medicare Beneficiary: Medicaid Coverage” (rev. 6/01) designed for new applicants which provides an explanation of QMB medicaid. An appropriately completed denial notice must be sent denying medicaid.

(b) When a medicare beneficiary is eligible for both QMB medicaid and delayed spenddown medicaid, the appropriate notice must indicate approval of both programs and must be accompanied by an JFS 07212 designed for new applicants which provides an explanation of QMB medicaid.

(c) When a medicare beneficiary is eligible for spenddown medicaid but not eligible for QMB medicaid, an approval notice shall be sent approving delayed spenddown medicaid and denying QMB medicaid.

(d) When a medicare beneficiary is eligible for medicaid and QMB medicaid, an approval notice shall be sent approving medicaid and QMB medicaid.

(e) When a medicare beneficiary is ineligible for QMB medicaid and for medicaid, a denial notice shall be sent denying both programs.

(7) A redetermination of QMB medicaid is required every twelve months.

(8) All QMBs must be placed on the buy-in program, in accordance with rule 5101:1-39-03 of the Administrative Code, effective the month QMB medicaid coverage begins.

(a) ODJFS will automatically place all QMB medicaid assistance groups on the buy-in using the appropriate health care date.

(b) If the QMB has dual eligibility for QMB medicaid and delayed spenddown medicaid, the case will also be placed on the buy-in using the effective date of the first of the month following the month that the QMB medicaid assistance group is authorized.

(c) If buy-in coverage should have been effective prior to the effective date that the QMB medicaid assistance group was entered in the electronic eligibility system, the CDJFS must manually buy-in the QMB back to the QMB medicaid eligibility beginning health care date.

(9) Individuals eligible for QMB medicaid but not enrolled for medicare part A will not have to be referred to their local social security administration (SSA) office to enroll. The part A state buy-in will create medicare part A entitlement (enrollment) as long as the individual has medicare part B. If the individual has neither, he must file an application for medicare part B with the local SSA office. Payment of the QMB’s medicare part A and part B premiums will be made through the buy-in process.

(10) QMB individuals receiving skilled care are eligible to have QMB medicaid pay their coinsurance. QMBs may have an obligation to pay a portion of or all of their patient liability towards their cost of care in the following situations:

(a) When medicare coverage ends, the level of care changes or medicaid covered leave days are used. The applicable medicaid per diem rate shall be used to calculate the cost of care in the long term care facility (LTCF).

(b) When the medicaid per diem rate exceeds the medicare per diem rate, the difference between the two rates shall be used to calculate the cost of care in the LTCF.

(11) Medicare beneficiaries receiving skilled care who are not covered by QMB medicaid will have an obligation to pay a portion of or all of their patient liability towards their cost of care in the following situations:

(a) When there is a coinsurance charge. The daily coinsurance amount shall be used to compute the cost of care.

(b) When medicare coverage ends, the level of care changes or medicaid covered leave days are used. The applicable medicaid rate shall be used to calculate the cost of care in the LTCF.

(c) When the medicaid per diem rate exceeds the medicare per diem rate. The difference between the two rates shall be used to calculate the cost of care in the LTCF.

(d) The cost of care remaining after the patient liability is applied is the ODJFS vendor payment amount.

(1) The SLMB medicaid benefit package is payment of the individual’s medicare part B premiums. Eligible individuals and couples:

(a) Are entitled to medicare part A hospital insurance benefits;

(b) Have income greater than the QMB medicaid income standard, but less than the SLMB medicaid income standard, in accordance with rule 5101:1-39-21 of the Administrative Code;

(c) Have countable resources that do not exceed twice the standard under the supplemental security income (SSI) program: four thousand dollars for an individual or six thousand dollars for a couple;

(d) Meet non-financial medicaid eligibility requirements in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code; and,

(e) May also qualify for full medicaid benefits.

(2) SLMBs do not receive a medicaid health card unless otherwise eligible for medicaid.

(3) Cost of living increases (COLAs) in Title II (social security) benefits are disregarded in determining the income of SLMBs through March of each year. For SLMBs the updated SLMB medicaid income standards are effective April first of each year.

(4) Individuals entitled to enroll for medicare hospital insurance benefits under part A as qualified working disabled individuals (QWDIs) as set forth in rule 5101:1-39-10.2 of the Administrative Code are not eligible for SLMB medicaid.

(5) An SLMB must meet the application and verification requirements as set forth in Chapter 5101:1-38 of the Administrative Code.

(6) Unless otherwise noted in this rule, SLMBs must meet the medicaid eligibility requirements as set forth in Chapters 5101:1-38 and 5101:1-39 of the Administrative Code.

(a) To determine SLMB medicaid eligibility, a medicare beneficiary’s income must be compared to the SLMB need medicaid income standard as set forth in rule 5101:1-39-21 of the Administrative Code.

(i) “Countable income” is the total income (both earned and unearned) in cash or in kind, less the exemptions and disregards outlined in rule 5101:1-39-18 of the Administrative Code; and income deemed to another in accordance with rule 5101:1-39-19 of the Administrative Code. After the deduction of each appropriate disregard, the subtotal is rounded down to the nearest whole dollar.

(ii) If countable income is greater than one hundred per cent of the federal poverty level and less than or equal to one hundred twenty per cent of the federal poverty level, the individual is eligible for SLMB medicaid.

(iii) If countable income exceeds one hundred twenty per cent of the federal poverty level, the individual is not eligible for SLMB medicaid.

(b) Medicare beneficiaries cannot spend down excess income to meet the SLMB need medicaid income standard.

(7) The effective date of SLMB medicaid eligibility is the first day of the month of application and for up to three months prior to the month of application provided all eligibility requirements are met in the month of application and in each retroactive month.

(8) Medicaid applicants who are entitled to medicare part A must have eligibility determined for medicaid and all categories of low-income medicare beneficiary medicaid. The individual may choose to accept both medicaid and SLMB medicaid or to decline medicaid or SLMB medicaid after they have been advised of the benefits of each category.

(a) When a medicare beneficiary is eligible for SLMB medicaid but not eligible for medicaid, a notice shall be sent approving SLMB medicaid. A denial notice must be sent denying medicaid.

(b) When a medicare beneficiary is eligible for both SLMB medicaid and spenddown medicaid, the notice must indicate approval of both programs.

(c) When a medicare beneficiary is eligible for regular medicaid or spenddown medicaid but not eligible for SLMB medicaid, a notice shall be sent approving regular or spenddown medicaid and denying SLMB medicaid.

(d) When a medicare beneficiary is eligible for regular medicaid and SLMB medicaid, the notice must indicate approval of medicaid and SLMB medicaid.

(e) When a medicare beneficiary is ineligible for SLMB medicaid and for medicaid, a notice shall be sent denying both programs.

(9) A redetermination of SLMB medicaid is required every twelve months.

(10) All SLMBs must be placed on the buy-in program, in accordance with rule 5101:1-39-03 of the Administrative Code, effective the month SLMB medicaid coverage begins.

(D) Qualified individuals (QI)

(1) QIs are individuals who would be QMBs or SLMBs but for the fact that their income exceeds the income levels established for QMBs and SLMBs. The income requirement for a QI is income equal to or greater than one hundred twenty per cent and less than one hundred thirty-five per cent of poverty.

(2) QIs are eligible for payment of the full medicare part B premium.

(3) QIs have certain additional requirements for continued eligibility. These are as follows:

(a) Unlike QMBs and SLMBs, QIs cannot be dually eligible for medicaid and QI unless their only eligibility for medicaid is as a delayed spenddown.

(b) Retroactive eligibility of up to three calendar months applies if the individual met all QI eligibility criteria in the retroactive period and the retroactive period is no earlier than January first of that calendar year.

(d) Eligibility expires December thirty-first of each year. The individual must complete a reapplication for QI each year.

(e) As with SLMB, a medicaid health card will not be issued for QIs.

(4) All medicaid applicants who are entitled to medicare part A must have their eligibility determined for medicaid, QMB medicaid, SLMB medicaid, and QI.

(a) Eligibility for QI must be denied if the individual is eligible for medicaid or ongoing spenddown medicaid. An individual who is approved for delayed spenddown, can also be approved for QI. This includes individuals who are approved as a delayed spenddown and choose to use the pay-in spenddown process.

(b) All QMB medicaid and SLMB medicaid provisions apply to QIs except that the QI-1QI income limit is income greater than one hundred twenty per cent and less than one hundred thirty-five per cent of the federal poverty level. Increases in Title II benefits are disregarded for January, February and March of each year.

(5) QIs must be placed on the buy-in program, in accordance with rule 5101:1-39-03 of the Administrative Code, effective the month QI medicaid coverage begins.

(6) If a QI becomes eligible for another category of medicaid other than delayed spenddown, the CDJFS must propose to terminate QI eligibility.

(7) The CDJFS must permit all individuals to apply for QI assistance during a calendar year. However, because of the capped allotment, the number of QIs approved cannot exceed the state’s allocation. Applications shall be approved on a first come-first served basis. Once a QI has been approved, the recipient is entitled to continue to receive assistance for the remainder of the calendar year, as long as the individual continues to meet the QI eligibility requirements. However, the fact that an individual receives assistance at any time during the year does not necessarily entitle the individual to continued assistance for any succeeding year. ODJFS will monitor the number of slots being used and will stop approving new applications when the allocation for the year has been reached.

Replaces: Part of 5101:1-39-22.2 and 5101:1-39-95

Effective: 07/01/2005

R.C. 119.032 review dates: 10/01/2007

Promulgated Under: 111.15

Statutory Authority: 5111.01

Rule Amplifies: 5111.01, 5111.012

Prior Effective Dates: 1/1/89 (emer.), 4/1/89, 1/1/90 (emer.), 1/5/90 (emer.), 4/1/90, 7/1/90 (emer.), 9/8/90, 9/28/90 (emer.), 12/24/90, 1/1/92 (emer.), 3/20/92, 7/1/92, 1/1/93 (emer.), 3/18/93, 6/11/93, 8/15/93, 3/1/94 (emer.), 4/18/94 (emer.), 6/1/98, 8/12/98 (emer.), 11/1/98, 10/01/02