Current through Register Vol. 24-18, September 15, 2024
(1) Available programs. The medicaid agency
offers eligible clients the following medicare savings programs (MSPs):
(a) The qualified medicare beneficiary (QMB)
program;
(b) The specified
low-income medicare beneficiary (SLMB) program;
(c) The qualified individual (QI-1) program;
and
(d) The qualified disabled and
working individuals (QDWI) program.
(2) Eligibility requirements.
(a) To be eligible for an MSP, a client must:
(i) Be entitled to medicare Part A;
and
(ii) Meet the general
eligibility requirements under WAC
182-503-0505.
(b) To be eligible for QDWI, a
client must be under age 65.
(c)
Income limits.
(ii) If a client's countable income is less
than or equal to 110 percent of the federal poverty level (FPL), the client is
income eligible for the QMB program.
(iii) If a client's countable income is over
110 percent of the FPL, but does not exceed 120 percent of the FPL, the client
is income eligible for the SLMB program.
(iv) If a client's countable income is over
120 percent of the FPL, but does not exceed 138 percent of the FPL, the client
is income eligible for the QI-1 program.
(v) If a client's countable income is over
138 percent of the FPL, but does not exceed 200 percent of the FPL, the client
is income eligible for the QDWI program if the client is employed and meets
disability requirements described in WAC
182-512-0050.
(d) The federal MSPs do not
require a resource test.
(3) MSP income eligibility determinations.
(a) The agency has two methods for
determining if a client is eligible for an MSP:
(i) The agency first determines if the client
is eligible based on SSI-rated methodologies under chapter 182-512 WAC. Under
this method, the agency calculates the household's net countable income and
compares the result to the one-person standard. However, if the spouse's income
is deemed to the client, or if both spouses are applying, the household's net
countable income is compared to the two-person standard.
(ii) If the client is not eligible under the
methodology described in (a)(i) of this subsection, the agency compares the
same countable income, as determined under (a)(i) of this subsection, to the
appropriate FPL standard based on family size. The number of individuals that
count for family size include:
(A) The
client;
(B) The client's spouse who
lives with the client;
(C) The
client's dependents who live with the client;
(D) The spouse's dependents who live with the
spouse, if the spouse lives with the client; and
(E) Any unborn children of the client, or of
the spouse if the spouse lives with the client.
(b) Under both eligibility determinations,
the agency follows the rules for SSI-related people under chapter 182-512 WAC
for determining:
(i) Countable
income;
(ii) Availability of
income;
(iii) Allowable income
deductions and exclusions; and
(iv)
Deemed income from and allocated income to a nonapplying spouse and
dependents.
(c) The
agency uses the eligibility determination that provides the client with the
highest level of coverage.
(i) If the MSP
applicant is eligible for QMB coverage under (a)(i) of this subsection, the
agency approves the coverage.
(ii)
If the MSP applicant is not eligible for QMB coverage, the agency determines if
the applicant is eligible under (a)(ii) of this subsection.
(iii) If neither eligibility determination
results in QMB coverage, the agency uses the same process to determine if the
client is eligible under any other MSP.
(d) When calculating income under this
section:
(i) The agency subtracts client
participation from a long-term care client's countable income under WAC
182-513-1380,
182-515-1509, or
182-515-1514.
(ii) The agency counts the annual Social
Security cost-of-living increase beginning April 1st each year.
(4) Covered costs.
(a) The QMB program pays:
(i) Medicare Part A and Part B premiums using
the start date in WAC
182-504-0025; and
(ii) Medicare coinsurance, copayments, and
deductibles for Part A, Part B, and Part C, subject to the limitations in WAC
182-502-0110.
(b) If the client is eligible for
both SLMB and another medicaid program:
(i)
The SLMB program pays the Part B premiums using the start date in WAC
182-504-0025; and
(ii) The medicaid program pays medicare
coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject
to the limitations in WAC
182-502-0110.
(c) If the client is only eligible
for SLMB, the SLMB program covers medicare Part B premiums using the start date
in WAC 182-504-0025.
(d) The QI-1 program pays medicare Part B
premiums using the start date in WAC
182-504-0025 until the agency's
federal funding allotment is spent. The agency resumes QI-1 benefit payments
the beginning of the next calendar year.
(e) The QDWI program covers medicare Part A
premiums using the start date in WAC
182-504-0025.
(5) MSP eligibility. Medicaid
eligibility may affect MSP eligibility:
(a)
QMB and SLMB clients may receive medicaid and still be eligible to receive QMB
or SLMB benefits.
(b) QI-1 and QDWI
clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI
benefits, but may be eligible for the state-funded medicare buy-in program
under WAC
182-517-0300.
(6) Right to request
administrative hearing. A person who disagrees with agency action under this
section may request an administrative hearing under chapter 182-526
WAC.
11-23-091, recodified as WAC 182-517-0100, filed 11/17/11,
effective 11/21/11. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500 and
42 U.S.C.
9902(2). 06-16-026, §
388-478-0085, filed 7/24/06, effective 8/24/06; 05-17-157, § 388-478-0085,
filed 8/22/05, effective 9/22/05. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500,
42 U.S.C.
9902(2). 04-17-076, §
388-478-0085, filed 8/13/04, effective 9/13/04. Statutory Authority:
RCW
74.08.090,
74.04.050,
74.04.057,
74.09.530, and Section 673(2) (
42 U.S.C.
9902(2)) . 01-18-056, §
388-478-0085, filed 8/30/01, effective 9/30/01; 00-17-085, § 388-478-0085,
filed 8/14/00, effective 9/14/00; 99-19-005, § 388-478-0085, filed 9/3/99,
effective 10/4/99. Statutory Authority:
RCW
74.04.050,
74.04.055,
74.04.057 and
74.08.090. 98-16-044, §
388-478-0085, filed 7/31/98, effective 9/1/98. Formerly WAC 388-517-1715,
388-517-1730, 388-517-1750 and
388-517-1770.
