Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.95-004 - 1995 Federal Poverty Income Guidelines for Certain Medicaid Categories

2047 Qualified Medicare Beneficiaries Under the Medicare Catastrophic Coverage Act of 1988

Section 301 of Public Law 100-360, the Medicare Catastrophic Coverage Act of 1988, requires Medicaid buy-in of Medicare premiums and coverage of deductibles and coinsurance for Qualified Medicare Beneficiaries (QMBs) with income at or below specified percentages of the poverty level and resources at or below twice the SSI limit.

2047.1 Scope of Services

Qualified Medicare Beneficiaries under the Medicare Catastrophic Coverage Act are not eligible for the full range of Medicaid Services. QMBs are eligible only for payment of all Medicare premiums, deductibles, and coinsurance.

QMBs will not be eligible for any retroactive coverage as QMBs. Coverage of Medicare premiums, deductibles, and coinsurance will begin on the first of the month following the month of approval, where an individual is found eligible as a QMB.

Individuals who apply for coverage as QMBs and who have medical expenses in prior months may be considered in other Medicaid categories (including spend-down categories) for the retroactive coverage.

With the exception of spend-down categories, an individual may not be certified in a QMB category and in another Medicaid category for simultaneous periods. If an individual is eligible in a category other than QMB, he will be eligible for and receive the QMB benefits along with the other Medicaid benefits (Re MS 2047.8). If an individual could be eligible in either a QMB category or a non-QMB category, the individual should be approved in the non-QMB category. Example: An individual is eligible in both categories 41 and 48; the individual will be certified in category 41, but will receive full QMB benefits.

An individual may be approved for a spend-down and as a QMB for simultaneous periods. Example: An individual applies for QMB coverage and for other Medicaid categories on March 1 and has sufficient non-coverable medical bills for a spend-down period of March, April, and May. QMB coverage is approved on March 30. QMB coverage will begin April 1. For any concurrent months of QMB and spend-down eligibility, Medicare premiums may not be considered as a non-coverable medical expense.

2047.2 Eligibility Requirements

QMBs must meet the following eligibility requirements:

2047.3 Medicare Part A Entitlement

A QMB must be entitled to or conditionally eligible for hospital insurance benefits under Medicare Part A. Medicare Part A beneficiaries include the following groups:

2048.4 Income Determination

The income of an ineligible spouse will be deemed to the QDWI applicant (Re. MS 2111-2111.5) and the net income compared to the couple's QDWI limit.

The income of an eligible couple will be totaled, and SSI exclusions will be given (only one $20 exclusion). The net income for the couple will be compared to the couple's QDWI income limit.

The income of QDWI's may vary monthly due to their income from employment. MS 3343 will be utilized in the determination and verification of earnings from employment.

2048.5 Initial Enrollment Period (IEP) and General Enrollment Period for Medicare Part A

A QDWI applicant must reenroll for Medicare Part A, if he/she has not previously reenrolled prior to making application.

The Social Security Administration will send notices to those individuals who lost or will lose Medicare Part A solely due to SGA, advising them to contact the SSA office. Once reapplication has been made for Medicare Part A, SSA will refer potentially eligible individuals to the County Office to make a QDWI application.

If an individual applies at the County Office prior to reenrolling for Medicare Part A, the individual will be instructed to go to the SSA Office to reenroll for Medicare Part A and provide verification of reenrollment and the effective date of coverage.

The Individual Enrollment Period begins with the month in which the individual receives notice from SSA that his/her entitlement to Disability and Medicare will end solely due to SGA. The enrollment period ends 7 months later.

There will also be a General Enrollment Period each year from January 1 - March 31.

2048.6 Disposition and System Procedures

Approval:

If all eligibility factors have been met, and the case is approved, the Service Representative will perform the following tasks:

2051.4 Period of Eligibility

2051.5 Disposition and System Procedures

2062.4 Changes in the Transitional Medicaid Period

Minor children entering the household, who were not in the budget group at the time the group became AFDC ineligible, will not be eligible for Transitional Medicaid and will not be added to the case. If an excluded child has earnings, they will not be considered in computing the family's average gross monthly earnings. The Service Representative will determine eligibility for this child in another category, counting only the child and the child's parent(s) in the unit, and considering only their income.

Minor children, who were in the home and included in the AFDC grant during the last month of AFDC eligibility, who later leave the home, will be dropped (a 10 day notice will be given). If he/she subsequently reenters the home while the family is receiving TM, he/she will be added to the Transitional Medicaid case. Any earnings that this child may have will be considered in computing the family's average gross monthly earnings.

The return of an absent parent to the home during Transitional Medicaid is not, in itself, a reason for closure (i.e., deprivation is not an eligibility factor for Transitional Medicaid). The absent parent who returns, if he/she was not in the budget group at the time of AFDC case closure, will not be eligible for Transitional Medicaid and will not be added to the case. Any earnings of the absent parent, however, will be used in computing the family's average gross monthly earnings.

If the only child in the home becomes eligible for SSI, the parent(s) (or non-parent specified relative) will remain eligible for Transitional Medicaid as long as the SSI child is under age 18. However, the County will receive a Systems Action Report notifying them that the case has been closed. The Service Representative will reopen the Transitional Medicaid case for the adults(s) by using a "B" action type and "096" action reason. The Transitional Medicaid Status on WATM will be changed to open status. The adult(s) must continue to meet all other eligibility requirements in order to remain eligible for Transitional Medicaid.

2062.5 System Closures. System Reports, and County Responsibilities

On the first workday of each month the system will search all Transitional Medicaid records for children who will reach the age of 18 that month. If the only child in the home is reaching age 18, the system will close the case and send a notice of case closure to the family. If there are other children under 18 in the home, the system will close only the 18 year old and leave the remaining individuals open.

The Counties will receive a Systems Action Report that will inform them of Transitional Medicaid 18 year olds and cases closed by the system.

When the system has closed an 18 year old, or at any time a member or a case is found ineligible for Transitional Medicaid, the County Office will make a determination and document the case record as to whether or not the ineligible member(s) meets the eligibility criteria in any other Medicaid Category (e.g., PW, MN-SD, etc.). If it appears that a member or the case would be eligible in another category, an application and notice of potential benefits will be sent to the individual(s).

The system will continue to close cases becoming AFDC ineligible due to the loss of the 1/3, or $30 earned income exclusions. A system notice will be generated to inform the individuals of Transitional Medicaid eligibility, and these cases will be converted by the system to Category 25 for Transitional Medicaid. These cases will also be listed on the Systems Action Report.

During the Additional 6 Months TM Extension Period (Second Six Months), a monthly report titled "Transitional Medicaid Cases" will be generated to the Counties to assist them in tracking the Transitional Medicaid cases. This report will list the Case Number, Casehead Name, Worker Number, Transitional Medicaid Begin Date, Current Month of Transitional Medicaid and the next month in which a Transitional Medicaid Report (EMS-124) is due.

At the end of the 12th month, the system will send a notice and close all Transitional Medicaid cases which remained open throughout both 6 month periods.

2062.6 Summary of Sequence of Notices/Reports in Transitional Medicaid Found AFDC ineligible prospectively. Determined Transitional Medicaid eligible:

Form EMS-123 manually issued to family.

Initial 6 months Extension Period 1st Month

1st month of AFDC ineligibility.

Monthly Standards (4/1/951

5740 Periods of Eligibility

5740.1 Pregnant Woman Eligibility Period - Retroactive. "No Look Back"

and Post partum Coverage

S0BRA eligibility for a pregnant woman may begin at any time during a medically verified pregnancy, and will be extended through the end of the month in which the 60th day postpartum falls. A PW who applies postpartum and is found S0BRA eligible in the month of delivery will be given the full postpartum coverage.

In determining eligibility for the PW, the worker must inquire if the PW had any medical bills of her own (paid or unpaid) in the 3 months prior to the date of application and, if so, determine retroactive eligibility for the retroactive period (there must be medical bills to give retroactive coverage and the medical bills must be verified - the bills must be for the PW - medical bills for other family members wi 11 not quali fy the PW for retroactive PW coverage); i f retroactive coverage is not given, the case record should be clearly documented to show that coverage was considered and why it was not given.

In conjunction with consideration of the retroactive coverage, if an applicant is found eligible in any of the 3 retroactive months, certify the case effective the earliest retroactive month of eligibility; there will be a "No Look Back" at later income increases, throughout the pregnancy and the postpartum period, even if the applicant is not income eligible in the month of application or in the month in which the 45th day of the application falls.

Example: Mrs. Smith applies for S0BRA coverage on November 1, and is not income eligible in November or in December (the month, in which the worker is ready to dispose of the application). However, Mrs. Smith was income eligible and had incurred medical bills in August, September and October. The County will certify Mrs. Smith for S0BRA coverage effective on the date of the earliest bill incurred during the retroactive period (but not more than 3 months prior to the date of application), and will not "look back" at her eligibility again (i.e., disregard the income increase that made her ineligible in November, the month of application).

When the PW is eligible, the full postpartum coverage must be provided, as mandated by law. Based on the expected date of delivery given by the PW, begin counting 60 days on the calendar, with the delivery date as day one; the end of Medicaid coverage will be the last day of the month in which the 60th day falls.

Example: Mrs. Jones' expected delivery date is November 15, and the 60th day after November 15th is January 13th. Coverage will be given through January 31st.

The client will be given the responsibility of reporting a premature delivery or delayed delivery.

5740.2 Infant/Child Eligibility Period

SOBRA eligible infants/children born after September 30, 1983, will remain eligible through the end of the month of their birthday, as specified below, as long as they remain income and resource eligible and as long as they reside with their parent(s), or other specified relatives (Re. FA 2250 - 2252). Children born prior to October 1, 1983, are not eligible under SOBRA.

If an infant/child is an inpatient on his/her birthday, as specified below, eligibility will continue until the end of the inpatient stay, provided the infant/child remains income and resource eligible. (Infants/children with severe disabilities will be referred to Social Security for SSI determination).

Application made after termination of a pregnancy does not prohibit coverage for the infant/child, i.e., a mother need not be a certified Medicaid recipient at the infant's birth in order for the infant/child to receive SOBRA coverage, as specified below. A mother need not remain Medicaid eligible in order for the infant/child to qualify for continuing coverage.