Lawriter - OAC - 5160:1-3-02.1 Medicare premium assistance programs (MPAP).

5160:1-3-02.1 Medicare premium assistance programs (MPAP).

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

(B) Definitions.

(1) "Eligible," for the purpose of this rule, means an individual meets all the requirements to enroll in MPAP.

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

(3) "Entitled" for the purpose of this rule, means an individual has coverage under medicare through the social security administration (SSA).

(4) "Family," for the purposes of MPAP, means the following persons living in the same household as the individual for whom medicare premium assistance is sought or received:

(a) The individual; and

(b) If the individual is a minor, then the biological, adoptive, step parents, legal guardians, or legal custodians of the individual; and

(c) The spouse of the individual and of any persons described in paragraph (B)(4)(b) of this rule; and

(d) The minor biological, adopted, or step child(ren) of the individual and of any persons described in paragraphs (B)(4)(b) and (B)(4)(c) of this rule.

(5) "Family of the size involved" means "family" as defined in paragraph (B)(4) of this rule.

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

(7) "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, 2016), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U).

(8) "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.

(9) "QDWI" means the qualified disabled and working individuals program established by section 1905(s) of the Social Security Act (as in effect on January 1, 2016). This program is sometimes referred to as the qualified working disabled individuals (QWDI) program.

(10) "QI-1" means the qualified individual group, described in section 1902(a)(10)(E)(iv) of the Social Security Act (as in effect on January 1, 2016).

(11) "QMB" means the qualified medicare beneficiary group described in section 1905(p)(1) of the Social Security Act (as in effect on January 1, 2016).

(12) "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, 2016).

(C) The income standards for the medicare premium assistance programs (MPAP) are as follows:

(1) The QMB income standard is one hundred percent of the federal poverty level for the family of the size involved.

(2) The SLMB income standard is greater than one hundred percent of the federal poverty level and up to a maximum one hundred twenty percent of the federal poverty level for the family of the size involved.

(3) The QI-1 income standard is greater than one hundred twenty percent of the federal poverty level and up to a maximum one hundred thirty-five percent of the federal poverty level for the family of the size involved.

(4) The QDWI income standard is two hundred percent of the federal poverty level for the family of the size involved.

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

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

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

(d) An individual otherwise qualified for QDWI must be enrolled in part A under section 1818A of the Social Security Act (as in effect on February 1, 2016). Coverage can be identified as being provided under section 1818A of the Social Security Act when the individual meets the following criteria:

(i) Has not reached age sixty-five; and

(ii) Has lost disability benefits under Title II of the Social Security Act (as in effect on February 1, 2016) solely due to earnings in excess of the substantial gainful activity (SGA) level established by the SSA; and

(iii) Is paying a premium for part A coverage; and

(iv) Has provided no document or communication from the SSA indicating another basis for part A coverage.

(2) Have countable resources, as determined under Chapter 5160:1-3 of the Administrative Code, no greater than the MPAP resource limit as defined in paragraph (B)(7) of this rule for the family of the size involved.

(3) Have countable income, as determined under paragraph (E) of this rule, within the MPAP income standards as set forth in paragraph (C) of this rule.

(4) For QI-1 and QDWI, be otherwise ineligible for medical assistance under Chapters 5160:1-1 to 5160:1-5 of the Administrative Code.

(5) Meet the application, conditions of eligibility, and verification requirements set forth in Chapter 5160:1-2 of the Administrative Code.

(E) Countable income shall be determined under Chapter 5160:1-3 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 continuing through the end of the month after the month in which the updated federal poverty guidelines are published in the Federal Register.

(F) Application of income standards.

(1) If the individual is a minor, the income of the individual combined with the income of the individual's biological, adoptive, step parents, legal guardians, or legal custodians (if any), and if married, the income of the individual's spouse is compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved.

(2) The income of the individual combined with the income of the individual's spouse (if any) is compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved.

(3) The income of both the individual and the individual's spouse (if any) must be determined in accordance with rule 5160:1-3-03.1 of the Administrative Code and applying all exclusions listed in rule 5160:1-3-03.2 of the Administrative Code, except that the twenty-dollar general and sixty-five-dollar earned income exclusions shall be applied only once to a married couple in the MPAP eligibility determination.

(4) The deeming provisions set forth in rule 5160:1-3-03.3 of the Administrative Code do not apply to MPAP eligibility determinations.

(G) Coordination of enrollment. If an individual is eligible for benefits under this rule, the county department of job and family services (CDJFS) may coordinate the individual's receipt of benefits.

(1) If the individual:

(a) Is or has ever been in receipt of medicare part A or part B benefits, the CDJFS may approve MPAP benefits for the individual in the electronic eligibility system.

(b) Has never received medicare part A or part B benefits, the CDJFS shall:

(i) Inform the individual that the Ohio department of medicaid (ODM) can not pay medicare premiums until the individual has enrolled in medicare part A or part B through the SSA; and

(ii) Advise the individual to apply for medicare part A or part B benefits through the SSA, and advise the individual that the CDJFS will assist upon request; and

(iii) Advise the individual to report the approval of part medicare A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(iv) Approve MPAP benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled in medicare part A or part B by the SSA .

(2) After three weeks, if the electronic submission was not successful, the CDJFS shall submit a completed ODM 07102 "Changes in Medicaid Health Care Coverage Date and Medicare Buy-In Eligibility" (rev. 07/2014) to the ODM buy-in unit.

(H) 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) Eligibility for QI-1 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 any part of the three-month period.

(4) Eligibility for QDWI 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.

(5) Eligibility for payment of medicare premiums under this rule ends on the earliest of the following dates:

(a) The last day of the month in which the individual dies; or

(b) The last day of the last month in which the individual is entitled to part B benefits; or

(c) The last day of the last month in which the individual meets the eligibility criteria for MPAP, if notice was provided to the centers for medicare and medicaid (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS receives notice the individual was no longer eligible for MPAP, if notice was not provided within the time limit in paragraph (H)(5)(c) of this rule.

(I) 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, for 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.

(3) If an individual is eligible for QDWI the administrative agency shall pay the individual's part A premiums.

(4) The medicare prescription drug benefit program (part D) is not covered by MPAP.

(J) Administrative agency responsibilities. The administrative agency shall:

(1) Explore eligibility for medical assistance and for all MPAP categories if a medical assistance applicant is qualified for medicare part A. The agency shall advise the individual:

(a) Of the categories of medical assistance 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 medicare part A or part B, ODM is prohibited from paying for prescriptions on behalf of that individual, whether or not a premium would be charged for those benefits.

(2) Determine if an individual is eligible for QMB and if eligible:

(a) Approve benefits under QMB effective the month after the administrative agency approves QMB coverage; and

(b) For individuals who are not receiving free medicare part A, but who could receive medicare part A benefits by paying a premium, coordinate enrollment in medicare parts A and B with ODM and SSA.

(3) Determine if an individual is eligible for SLMB and if eligible approve benefits under SLMB effective the month SLMB coverage begins.

(4) Determine if an individual is eligible for QI-1 and if eligible approve benefits under QI-1 effective the month QI-1 coverage begins.

(5) Determine if an individual is eligible for QDWI and if eligible approve benefits under QDWI effective the month that QDWI coverage begins.

(6) 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 ODM manually enter coverage for the individual with the correct coverage effective date.

(7) Deny benefits under this rule if:

(a) Any of the criteria under this rule is not met; or

(b) Any of the conditions for denial set forth in rule 5160:1-2-01 of the Administrative Code are met.

(8) 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 5160:1-2-01 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.

(9) Coordinate enrollment with the individual, the SSA, and ODM's buy-in unit.

(K) Individual responsibilities. An individual:

(1) Must inform the CDJFS of any actions by the SSA on the individual's application for medicare part A or part B, or any changes in the individual's medicare part A or part B coverage.

(2) Must adhere to the individual responsibilities set forth in rule 5160:1-2-08 of the Administrative Code.

Replaces: 5160:1-3- 02.1, 5160:1-3- 02.2


Effective: 7/1/2016
Five Year Review (FYR) Dates: 07/01/2021
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02
Rule Amplifies: 5160.02, 5163.02
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, 1/1/1991, 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, 1/1/2010, 1/22/2015