0865.010.05.15 Part A Conditional Enrollment – DSS Manuals

IM-47 May 14, 2020

Individuals age 65 and over who are eligible for Part A coverage only if they pay a premium, may conditionally enroll in Part A pending a determination of eligibility for QMB. In this way, they are able to elect to receive Part A only if the premiums are paid by the state.

Interested individuals must contact Social Security Administration (SSA) during the open enrollment period, or during the seven month eligibility period around their 65th birthday, and conditionally enroll for Part A Medicare. SSA then refers the participant to Family Support Division for a QMB eligibility determination.

Participants who are referred to FSD must request QMB application, or a QMB eligibility determination on an active assistance case. The participant may provide a receipt from SSA as proof of application for Part A Medicare. The receipt contains the Part A Medicare application date. It does not state that the enrollment is conditional. This receipt is proof only of application for Part A Medicare; it is not proof of entitlement.

After the QMB application/request is made, staff must view IIVE for verification of Part A Medicare eligibility. The SSA application process for Part A takes 2-4 weeks to complete; therefore, IIVE may not show Part A Medicare participation immediately.

Proof of conditional enrollment is shown on IIVE by a code of “Z99” in the field following the Hospital Insurance information, and includes an entitlement date. The “Z99” indicates that this is a conditional enrollment, and is considered as verification of Part A participation. It will be changed by SSA to a Missouri payer code when buy-in for Part A is complete.

In no instance should the client be approved for QMB coverage without verification of Part A eligibility.

For conditional enrollment cases, if the IIVE is returned showing no Part A entitlement, staff must contact SSA for clarification before the QMB application is rejected for no participation in Part A Medicare.

Make a determination of QMB eligibility on all factors including Part A participation. The effective date of QMB coverage must be the month following the month the determination is made, or the effective date of Part A entitlement, whichever is later.

NOTE: Part A Conditional Enrollment status is not valid Part A eligibility for the Specified Low-Income Beneficiary (SLMB) program. SLMB will only pay for Medicare Part B. SLMB cannot be approved for an individual with conditional Medicare Part A.