Revision 13-3; Effective September 1, 2013

 

This chapter describes the Medicare Savings Programs. The Medicare Savings Programs use Medicaid funds to help eligible persons pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles or coinsurance.

HHSC manages the Medicare Savings Programs, which consists of the following:

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled and Working Individual (QDWI) Program

Countable resource limits for Medicare Savings Programs (except QDWI) are indexed each year based on the Consumer Price Index. QDWI requires a person to have countable resources equal to or less than twice the limits for the SSI program to be eligible based on resources. The treatment of income and resources is based on policy in Chapter E, General Income, and Chapter F, Resources. Application and redetermination policies for Medicare Savings Programs adhere to policy and procedure in Chapter B, Applications and Redeterminations. Transfer of assets, spousal impoverishment and co-payment policy and procedures are not used in the Medicare Savings Programs.

All Medicare Savings Programs require a person to meet non-financial eligibility requirements described in Chapter D, Non-Financial.

 

Q-1100 Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

§359.101. Purpose and Scope.

(a) This chapter describes the assistance available and eligibility requirements for the Medicare Savings Program. Authorized under 42 U.S.C. §1396a(a)(10)(E), the Medicare Savings Program uses Medicaid funds to help eligible persons pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.

(b) The Texas Health and Human Services Commission (HHSC) manages the Medicare Savings Program, which consists of the following:

(1) the Qualified Medicare Beneficiary (QMB) Program;

(2) the Specified Low-Income Medicare Beneficiary (SLMB) Program;

(3) the Qualified Individual (QI) Program; and

(4) the Qualified Disabled and Working Individual (QDWI) Program.

(c) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.

 

§359.103. Qualified Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(i), the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles, and coinsurance for a person who meets the requirements of this section. A person receiving Medicaid may also receive QMB benefits if the person meets the requirements of this section.

(b) To be eligible for QMB coverage, a person must:

(1) be entitled to benefits under Medicare Part A; and

(2) meet income and resources requirements in 42 U.S.C. §1396d(p).

(c) A person is not eligible for QMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's QMB eligibility begins on the first day of the month after the month the person is certified for QMB benefits.

(e) A person with QMB coverage is not eligible for three months prior medical coverage.

 

§359.105. Specified Low-Income Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iii), the Specified Low-Income Medicare Beneficiary (SLMB) Program pays only Medicare Part B premiums for a person who meets the requirements of this section. A person receiving Medicaid may also receive SLMB benefits if the person meets the requirements of this section.

(b) To be eligible for SLMB coverage, a person must meet the eligibility criteria for QMB coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have an income that is greater than 100% but less than 120% of the federal poverty level.

(c) A person is not eligible for SLMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's SLMB eligibility may begin with the month of application.

(e) A person with SLMB coverage is eligible for three months prior medical coverage, if all criteria are met.

 

§359.107. Qualifying Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iv) the Qualifying Individual (QI) Program pays only Medicare Part B premiums to a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QI coverage at the same time.

(b) To be eligible for QI coverage, a person must meet the eligibility criteria for Qualified Medicare Beneficiary coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have income that is at least 120% but less than 135% of the federal poverty level.

(c) Eligibility for QI coverage is determined for each calendar year.

(d) A person's QI eligibility may begin with the month of application.

(e) A person with QI coverage is eligible for three months prior medical coverage if all criteria are met. The three-month prior period cannot extend back into the previous calendar year.

 

§359.109. Qualified Disabled and Working Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(ii), the Qualified Disabled and Working Individual (QDWI) Program pays only Medicare Part A premiums for a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QDWI coverage at the same time.

(b) To be eligible for QDWI coverage, a person must:

(1) be under 65 years of age;

(2) be entitled to benefits under Medicare Part A;

(3) not otherwise be eligible for Medicaid;

(4) have a monthly income equal to or less than 200% of the federal poverty level; and

(5) have no more than twice the countable resources allowed under the Supplemental Security Income (SSI) program, as described in §1611 of the Social Security Act (42 U.S.C. §1382).

(c) A person's QDWI eligibility begins in accordance with the coverage period described in §1818A of the Social Security Act (42 U.S.C. §1395i-2a(c)).

 

Q-1200 Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)

Revision 13-3; Effective September 1, 2013

 

Effective Jan. 1, 2010, the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) required changing the resource limits for the Medicare Savings Program (MSP) and added requirements for processing MSP applications for individuals applying through the Social Security Administration (SSA) for the Low Income Subsidy (LIS) program, also referred to as the Extra Help program. LIS provides prescription assistance for Medicare beneficiaries enrolled in Medicare Part D who have limited income and resources. The MSP programs included in MIPPA are:

  • Qualified Medicare Beneficiary (QMB) Program;
  • Specified Low-Income Medicare Beneficiary (SLMB) Program; and
  • Qualified Individual (QI) Program.

The Qualified Disabled and Working Individual (QDWI) Program is not part of MIPPA.

Texas receives a list of individuals who applied for LIS from SSA; the list includes individuals approved and denied. The date the lists are received by the Texas Health and Human Services Commission (HHSC) is the application date for MSP and starts the 45-day clock for processing the applications timely for each person on the list. The date the application was made with SSA is a protected file date for MSP eligibility. Form H1200EZ-MSP is sent to the individuals on the list. HHSC sends denied LIS applicants a denial notice with the right to appeal if the denial reason is:

  • Live outside the United States,
  • Have excess resources (using new resource limits), or
  • Individual with excess income (couples will not auto deny).

Additionally, TIERS will deny anyone identified as living outside of Texas

The H1200-EZ-MSP applications are processed by a specialized MEPD/MSP unit located in El Paso. Approved MSP cases are distributed so that the special and annual reviews can be processed by MEPD staff across the state. If other H1200 series applications are received, they are routed according to normal application channels for TIERS.

Processing instructions on the MIPPA applications can be obtained by Eligibility Services Field Operations Staff. These instructions can be found at https://oss.txhhsc.txnet.state.tx.us/sites/eo/fo/mepd/MEPD-TIERS_Processes/LIS-MSP_Application_Processing_Field_Processes_v_4.docx.