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8 TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE

Individuals who meet the eligibility requirements for Qualified Medicare Beneficiaries must be identified through the Medicaid identification card system as Qualified Medicare Beneficiaries. This is to alert providers that special coverage and reimbursement rules apply. Qualified Medicare Beneficiaries are Medicaid eligible and are entitled to the same rights and subject to responsibilities applicable to Medicaid eligibles (e.g., fair hearings and reporting requirements). For individuals eligible only as Qualified Medicare Beneficiaries, benefits are limited to medical assistance for Medicare cost-sharing expenses for services covered by Medicare. 17300.8 Payments to Providers

Subject to state law, a provider has the right to accept a patient either as private pay only or as a QMB only. The provider must advise the patient, for payment purposes, how he will be accepted. Medicaid payment of Medicare deductible and coinsurance amounts may be made only to Medicaid participating providers. Medicaid may make a payment even though a Medicare service is not covered by Medicaid in the State plan. The claim may not be rejected on the basis that the Medicare service is not covered by Medicaid or that the provider accepts the patient as a Qualified Medicare Beneficiary only. The actual payment made by Medicaid is payment in full for Medicare deductibles and coinsurance. The provider is restricted from seeking to collect any amount from the QMB for Medicare deductibles or co-insurance even if Medicaid's payment is less than the Medicare deductible and co-insurance. 17400 Specified Low Income Medicare Beneficiaries Section 4501(b) of the Omnibus Budget Reconciliation Act (OBRA) of 1990 mandates coverage of specified low- income Medicare beneficiaries beginning January 1, 1993. Medicaid will pay the Medicare Part B premium for these individuals. They do not receive any Medicaid services. A Specified Low-Income Medicare Beneficiary (SLMB) is an individual who meets all of the eligibility requirements for Qualified Medicare Beneficiary (QMB) status except for income in excess of the QMB income limit Follow all technical and financial eligibility requirements (except for income limits) described in the QMB program.

17400.1 Income Limits

The income limit is 110% of the Federal Poverty Level for calendar years 1993 and 1994. Effective for calendar years beginning 1995, the income limit is 120% of the FPL. The new poverty levels are effective April 1 for SLMBs who have title II income. For SLMBs without title II income, the new poverty levels are effective February 1.

17400.1.1 COLA Disregard

Social Security COLA increases will be excluded in determining the eligibility of recipients during the first three months of a calendar year.

17400.2 Retroactive Coverage

Retroactive eligibility does apply to this group unlike the QMB program. Benefits may begin with the month of application. Retroactive coverage is available for the three months prior to the month of application.

17400.3 Redetermination of Eligibility

A redetermination of eligibility must be completed at least every 12 months. We will promptly redetermine eligibility when information is received about changes in circumstances that may affect eligibility. 29 DE Reg. 604 (01/01/26)

17500 Qualifying Individuals

Section 4732 of the Balanced Budget Act of 1997 establishes a capped allocation for each of five years beginning January 1998, to states for payment of Medicare Part B premiums for two new mandatory eligibility groups of low-income Medicare beneficiaries, called Qualifying Individuals or QIs. This provision amends section 1902(a)(10)(E) of the Social Security Act concerning Medicare cost-sharing for Qualified Medicare Beneficiaries (QMBs) and Specified Low Income Medicare Beneficiaries (SLMBs). It also amends section 1905(b) of the Social Security Act concerning the Federal Medical Assistance Percentage (FMAP) by incorporating reference to and establishing a new section 1933, for QIs.

QIs are individuals who would be QMBs but for the fact that their income exceeds the income levels established for QMBs and SLMBs. This means that QIs must meet all the technical and financial eligibility requirements of the QMB program except for the income limits.

Unlike QMBs or SLMBs, who may be determined eligible for Medicaid benefits in addition to their QMB/SLMB benefits, QIs cannot be otherwise eligible for Medicaid.

17510 Qualifying Individuals 1

Individuals in the first group of QIs, called QI-1s, must have income that exceeds 120% of the Federal Poverty Level (FPL) but the income must be at or below 135% of the FPL. The benefit for QI-1s consists of payment of the full Medicare Part B premium. They do not receive any Medicaid services.

17520 Qualifying Individuals 2 QI-2 Eligibility Group - Expired: December 31, 2002

17530 COLA Disregard