5101:1-39-01.1 Medicare premium assistance programs (MPAP).

(A) This rule sets forth the eligibility criteria and benefits for the medicare premium assistance programs (MPAP). These programs are: qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), and qualified individuals (QI-1).

(B) Definitions.

(1) "Enrolled", for the purpose of this rule, means an individual is in receipt of benefits under a medicare health plan.

(2) "MPAP" means any or all of the medicare premium assistance programs: QMB, SLMB, and QI-1.

(3) "MPAP resource limit" means the maximum amount of resources allowed under section 1905(p)(1) of the Social Security Act (as in effect on January 1, 2010), as adjusted annually by the consumer price index for urban areas.

(4) "Qualified", for the purpose of this rule, means an individual is eligible to receive benefits under a medicare health plan, whether or not the individual has applied for those benefits.

(5) "QI-1" means the qualified individual group, for which federal funds are provided each year, described in section 1902(a)(10)(E)(iv) of the Social Security Act (as in effect on January 1, 2010). Enrollment for this group may be limited.

(6) "QMB" means the qualified medicare beneficiary group described in section 1905(p)(1) of the Social Security Act (as in effect on January 1, 2010).

(7) "SLMB" means the specified low-income medicare beneficiary group described in section 1902(a)(10)(E)(iii) of the Social Security Act (as in effect on January 1, 2010).

(C) Eligibility. To be eligible for a medicare premium assistance program, an individual must meet all of the following conditions: (1) Be qualified for coverage under medicare part A (part A).

(a) An individual is ineligible for MPAP benefits under this rule if the individual is receiving medicare benefits under section 1818A of the Social Security Act (as in effect on January 1, 2010), but the individual may be eligible for benefits under rule 5101:1-39-01.2 or 5101:1-41-30 of the Administrative Code. Rule 5101:1-39-01.2 of the Administrative Code describes individuals receiving benefits under section 1818A.

(b) An individual otherwise qualified for QMB must be enrolled in either part A or medicare part B ("part B") for the administrative agency to provide benefits under this rule.

(c) An individual otherwise qualified for SLMB or QI-1 must be enrolled in part A for the administrative agency to provide benefits under this rule.

(2) Have resources, as determined under Chapter 5101:1-39 of the Administrative Code, no greater than the MPAP resource limit for an individual or for a couple, whichever is appropriate.

(3) Have income, as determined under paragraph (D) of this rule, within the income limits for the MPAP: (a) For QMB, no greater than one hundred per cent of the federal poverty level (FPL) for the individual's family size; or (b) For SLMB, greater than one hundred per cent of the FPL but less than one hundred twenty per cent of the FPL for the individual's family size; or (c) For QI-1, at least one hundred twenty per cent of the FPL but less than one hundred thirty-five per cent of the FPL for the individual's family size.

(4) For QI-1, be otherwise ineligible for medical assistance under Chapters 5101:1-37 to 5101:1-41 of the Administrative Code. However, an individual who is eligible only with a delayed spenddown, as set forth in rule 5101:1-39-10 of the Administrative Code, is eligible for QI-1 benefits.

(5) Meet the application, conditions of eligibility, and verification requirements set forth in Chapter 5101:1-38 of the Administrative Code.

(D) Countable income shall be determined under Chapter 5101:1-39 of the Administrative Code except the annual cost of living increase (COLA) shall be deducted from the individual's income beginning in January of each year and ending the month after the COLA was published in the Federal Register.

(E) Coverage periods.

(1) The effective date of QMB coverage is the first day of the month after the month in which the administrative agency approves QMB benefits. No retroactive coverage is available for QMB.

(2) Eligibility for SLMB benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(3) QI-1 eligibility is limited by calendar year.

(a) QI-1 coverage begins on the first day of the month of application. If all eligibility requirements were met in any of the three months before the month of application, coverage begins three months before the month of application, except that retroactive coverage under QI-1 cannot begin earlier than January of that year.

(i) The individual must reapply for QI-1 coverage each year.

(ii) Federal funding is limited, and only a certain number of individuals can be covered. Applications are considered and individuals are approved for coverage on a first-come, first-served basis each year until the number of covered individuals equals that year's maximum.

(b) QI-1 coverage continues until December thirty-first of each year, except that coverage will end on the last day of the month in which the individual dies or ceases to be an Ohio resident.

(4) The date and effect of termination of MPAP benefits is set forth in rule 5101:1-38-03 of the Administrative Code.

(F) Benefits.

(1) If an individual is eligible for QMB, the administrative agency shall pay the individual's: (a) Premiums for part B and, if a premium is charged, part A; and (b) Medicare deductibles; and (c) Medicare co-pays; and (d) Medicare coinsurance costs.

(2) If an individual is eligible for SLMB or QI-1, the administrative agency shall pay the individual's part B premiums.

(G) Administrative agency responsibilities. The administrative agency shall: (1) Explore eligibility for medicaid and for all MPAP categories if a medicaid applicant is qualified for part A. The agency shall advise the individual: (a) Of the categories of medicaid or MPAP for which the individual is eligible, the individual's right to decline payment of premiums, co-pays, or coinsurance costs, and the effect of declining MPAP payments; and (b) That if an individual is qualified for benefits under part A or part B, whether or not a premium would be charged for those benefits, ODJFS is prohibited from paying for prescriptions on behalf of that individual.

(2) If an individual is eligible for QMB: (a) Approve benefits under QMB and pay the part A, if applicable, and part B premiums on behalf of a QMB-eligible individual as set forth in rule 5101:1-38-03 of the Administrative Code, effective the month after the CDJFS approves QMB coverage; and (b) Provide form JFS 07212 "Explanation of Qualified Medicare Beneficiary (QMB) Medicaid Coverage" (rev. 6/2001) to the individual; and (c) For individuals who are not receiving free part A, but who could receive part A benefits by paying a premium, coordinate enrollment in parts A and B with ODJFS and SSA.

(3) If the individual is eligible for SLMB, approve benefits under SLMB and pay the individual's part B premium as set forth in rule 5101:1-38-03 of the Administrative Code, effective the month SLMB coverage begins.

(4) If an individual is determined to be eligible for QI-1: (a) Approve QI-1 for eligible individuals on a first-come, first-served basis each year; and (b) Pay the individual's part B premium as set forth in rule 5101:1-38-03 of the Administrative Code, effective the month QI-1 coverage begins.

(5) Determine whether coverage for any category of benefits under this rule should have been effective prior to the effective date in the electronic medicare buy-in system. If coverage should have begun earlier, the CDJFS shall request that ODJFS manually buy-in the individual with the correct coverage effective date.

(6) Deny benefits under this rule if: (a) Any of the conditions for denial set forth in rule 5101:1-38-01 of the Administrative Code are met; or (b) The individual is eligible only for benefits under QI-1 and there is insufficient funding for the QI-1 program.

(7) Terminate benefits under this rule if: (a) An individual no longer meets the eligibility criteria for any covered group under this rule; or (b) Any of the conditions for termination set forth in rule 5101:1-38-01 of the Administrative Code are met; or (c) The individual was eligible for benefits under QI-1 but becomes eligible for another category of medicaid, including ongoing spenddown medicaid as set forth in rule 5101:1-39-10 of the Administrative Code.

(8) Coordinate enrollment with the individual, the SSA, and the buy-in unit of the Ohio department of job and family services (ODJFS).

(H) Individual responsibilities. An individual: (1) Who is otherwise eligible for QMB but who is not currently in receipt of part A or part B must apply at the SSA for part A or part B.

(2) Who is otherwise eligible for SLMB but who is not currently in receipt of part A must apply at the SSA for part A.

(3) Must inform the county department of job and family services (CDJFS) of any actions by the SSA on the individual's application for part A or part B, or any changes in the individual's part A or part B coverage.

Replaces:

5101:1-39- 01.1

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2015
Promulgated Under: 111.15
Statutory Authority: 5111.01
Rule Amplifies: 5111.01 , 5111.011
Prior Effective Dates: 1/1/1989 (Emer.), 4/1/1989, 1/1/1990 (Emer.),
1/5/1990 (Emer.), 4/1/1990, 7/1/1990 (Emer.), 9/8/1990, 9/28/1990 (Emer.), 12/24/1990, 1/1/1992 (Emer.), 3/20/1992, 7/1/1992, 1/1/1993 (Emer.), 3/18/1993, 6/11/1993, 8/15/1993, 3/1/1994 (Emer.), 4/18/1994 (Emer.), 6/1/1998, 8/12/1998 (Emer.), 11/1/1998, 10/01/2002, 7/1/2005