400.05.03 MEDICARE COST-SHARING GROUP – SLMB (SPECIFIED LOW-INCOME

MEDICARE BENEFICIARY) COE-051 Section 4501 of the Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508) mandated the coverage of SLMB’s for the purpose of paying Medicare Part B premiums. Federal and state law implemented this group effective January 1, 1993. At the time of implementation, the resource limit for SLMB’s was twice the SSI resource limits; however, effective 07/01/1999, liberalized policy removed the resource test for the Medicare cost-sharing groups of QMB, SLMB and QI. The QWDI group retained the resource limit equal to twice the SSI limits. A SLMB must meet all non-financial requirements of Medicaid eligibility. The exception is a DDS determination of disability for an individual under age 65. Medicare entitlement is proof of disability per policy outlined in Section 102, Non-Financial Requirements. To qualify for SLMB coverage, an individual or couple must meet all of the following criteria: • Each eligible individual must be entitled to Medicare Part A (Hospital Insurance). Refer to “Medicare Entitlement for SLMB-Only” below for further information. Note: The only exception to requirement or enrollment in Part A is individuals entitled to Medicare Part B-ID. Medicare Part B-ID, implemented January 2023 from the Consolidated Appropriations Act 2021, is solely for coverage of immunosuppressive drugs. Part B-ID may be awarded to individuals who lose Medicare entitlement based on end stage renal disease (ESRD) 36 months following a successful kidney transplant. Individuals are ineligible for Part B-ID if they have full Medicaid coverage that includes coverage for immunosuppressive drugs or other health insurance. • Countable income must not exceed 120% FPL. SLMB eligibility is limited to an individual or couple with income that exceeds 100% FPL (QMB limit) but does not exceed 120% FPL. • There is no resource test, but income produced by resources (interest, dividends, etc.) counts as income. Refer to Chapter 200, Income, at 200.02.02, Types of Income. Effective Date of SLMB Benefits Payment of a SLMB’s Medicare Part B or Medicare Part B-ID premium is effective with the first month of eligibility for SLMB-only, which includes up to 3 months prior to the month of application. The effective date of Medicare Part A, if applicable, must be equal or prior to the effective date of eligibility for SLMB. Example 1: An applicant with Medicare Parts A and B applies for SLMB-only in April. Retroactive eligibility is requested for all 3 months prior to April. The Medicare Part A and B effective date is August of the preceding year. SLMB eligibility can be determined retroactive to January. Example 2: An applicant with Medicare Part B only applies for SLMB coverage in April. The applicant is required to apply for Medicare Part A as part of the application process. Medicare Part A coverage is verified with an effective date of April 1, the same month as the Medicaid application for SLMB coverage. As a result, eligibility for SLMB can begin no earlier than April 1st. SLMB Benefits • An individual or couple eligible as SLMB-only qualifies for payment of their Medicare Part B or Part B-ID premiums only. Medicare Part B is Supplemental Medical Insurance or SMI. Medicare Part B-ID is solely for coverage of immunosuppressive drugs. SLMB Dual Eligibility An individual can be eligible as a SLMB and eligible in another full-service COE. Eligibility as a SLMB can constitute an eligibility status which is in addition to eligibility in another full-service coverage group. When an individual is eligible as a SLMB and in another category, this is known as SLMB dual eligibility. A recipient dually eligible as a SLMB and in another full-service COE receives the full range of Medicaid services and payment of Medicare Part B premiums and payment of Medicare Part A/B deductibles and co-insurance charges. There is no payment of Medicare Part A premiums for SLMB duals whose Part A is not free. Applicant’s Choice of Category An individual who would be eligible as a SLMB and in another full-service COE may choose to have eligibility determined under only one category; however, the individual is not required to make such a choice. The applicant is entitled to have eligibility determined under all categories for which he may qualify, such as SLMB dual status. However, an individual who would be eligible under more than one category can request to have eligibility determined only under the category he selects. NOTE: LIS applicants with income between 100% and 120% of the FPL are considered to be applying for SLMB-only. Medicare Entitlement for SLMB-Only An applicant for SLMB-only must have active Medicare Part A. Medicare is an enforceable utilization of other benefits requirement for an SLMB-only because Medicare will pay all associated premiums, deductibles and co-insurance under Part B, which is the only benefit payable for an SLMB-only. An SLMB-only applicant is someone with countable income at the budget level that exceeds 100% FPL but does not exceed 120% FPL. Note: The only exception to requirement to enroll in Part A is individuals entitled to Medicare Part B-ID. SLMB applicants may have: Medicare Part A only The Buy-In process will enroll the applicant in Medicare Part B after approval of the SLMB-only case. Medicare Part B only Applicant must apply for Medicare Part A and accept Part A even if not eligible for free Part A; otherwise SLMB-only eligibility is not possible. Do not approve an individual for SLMB-only unless or until Medicare Part A is verified. Applicant must apply for Part A even if applicant previously applied and refused, withdrew or was terminated due to failure to pay premiums (regardless of whether SSA requires repayment of past due premiums before reopening Part A.) NOTE: individuals in a full-service COE that have income within SLMB limits are not required to have Medicare Part A, but the individual is not “SLMB-dual” without Part A. This affects the Buy-In beginning date. Medicare Parts A and B Enter data in MEDS, no further action needed. Medicare Part B-ID The Buy-In process will pay Part B-ID monthly premiums only.