400.05.04A QI-1 GROUP

To qualify as a QI-1, 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 QI-1’s” 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 135% FPL. QI-1 eligibility is limited to individuals with income that exceeds 120% FPL (SLMB limit) but does not exceed 135% FPL. • There is no resource test for this group effective July 1, 1999; however, income produced by resources (interest, dividends, etc.) counts as income. Refer to Chapter 200, Income, at 200.02.02, Types of Income. • All other non-financial requirements of Medicaid eligibility must be met except for a DDS determination of disability for an individual under age 65 since Medicare entitlement is proof of disability. Effective Date of QI-1 Benefits Payment of a QI-1’s Medicare Part B or Medicare Part B-ID premium is effective with the first month of eligibility for QI-1, 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 QI-1, the same as for SLMB eligibility. QI-1 Benefits An individual or couple eligible as QI-1 qualifies for payment of their Medicare Part B or Medicare 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. Payment of the Medicare Part B or Part B-ID premiums continues for as long as the individual or couple is eligible or until the federal allotment for payment of Part B premiums is exhausted. In the event federal funds reached the allotted amount or the program failed to be reauthorized, advance notice to terminate benefits would be required. Dual Eligibility There is no dual eligibility for QI-1’s and any other full-service COE. A QI-1 is a stand-alone eligibility status for individuals who apply for QI-1 eligibility or who are not eligible for coverage in any other available COE. NOTE: LIS applicants with income between 120% and 135% of the FPL are considered to be applying for QI-1 coverage. Medicare Entitlement for QI-1’s An applicant for QI-1 must have active Medicare Part A. Medicare is an enforceable utilization of other benefits requirement for a QI-1 because Medicare will pay all associated premiums, deductibles and co-insurance under Part B, which is the only benefit payable for a QI-1. Note: The only exception to requirement to enroll in Part A is individuals entitled to Medicare Part B-ID. A QI-1 applicant is someone with countable income at the budget level that exceeds 120% FPL but does not exceed 135% FPL. QI-1 applicants may have: Medicare Part A only The Buy-In process will enroll the applicant in Medicare Part B after approval of the QI-1 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, QI-1 eligibility is not possible. Do not approve an individual for QI-1 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.) 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.