2675.5 Termination of Subsidy Coverage

When subsidy eligibility ends, the date actual coverage terminates depends on whether the individual was deemed or determined eligible.

Deemed Eligibles – An individual deemed eligible for subsidy coverage any time during the year will be continuously eligible thru December of that year. If deemed eligible for the month of July or later, subsidy coverage will be continuous through December of the next year. This automatic extension of coverage occurs even if the original underlying medical assistance has ended. Example 1 : An individual files an application for medical assistance and is deemed eligible for subsidy coverage effective February 2011. In June 2011 the medical case is closed and the individual is no longer deemed eligible. Even though medical assistance has ended effective June 30, 2011, deemed subsidy coverage automatically extends through the end of December 2011. Example 2 : Same situation as in Example 1, except the medical case closes effective August 31, 2011. Since this individual was deemed eligible on or after July 2011, subsidy coverage automatically extends through the end of December 2012.

Determined Eligibles – An individual determined eligible for subsidy coverage by Social Security will lose coverage effective with the date they no longer meet program requirements. There is no automatic extension of coverage for SSA determined eligibles. Example : An individual files an application with Social Security and is approved for subsidy coverage beginning in March 2011. Program eligibility requirements are no longer met in September 2011 and the case closes effective October 31, 2011. Determined subsidy coverage ends the date of program closure.

Competing Eligibility Records – A deemed eligibility record sent by the state to CMS will always override a SSA determined eligibility record. Therefore, once a deemed record has been received by CMS, the individual is eligible for coverage as indicated in 1. above, even if there is a prior existing determined record from SSA. Example : An individual files an application with Social Security and is approved for determined subsidy with coverage level 3 beginning April 2011. The individual later files an application for QMB coverage and is approved beginning July 2011 with deemed subsidy coverage. Once the deemed record is received by CMS, the individual will have subsidy coverage from July 2011 through December 2012 at the QMB level.