Rule 67:46:11:01 Definitions.

CHAPTER 67:46:11

QUALIFIED MEDICARE BENEFICIARIES (QMB)

Section

67:46:11:01 Definitions.

67:46:11:02 Long-term care requirements applicable to QI, QMB and SLMB.

67:46:11:03 Income eligibility.

67:46:11:04 Repealed.

67:46:11:05 Deduction for court-ordered support or support enforced by OCSE.

67:46:11:06 Items not considered income when determining QI, QMB or SLMB eligibility.

67:46:11:07 Income from self-employment.

67:46:11:08 Deduction from earned income.

67:46:11:09 Income disregard.

67:46:11:10 Repealed.

67:46:11:11 Disposal of resources.

67:46:11:12 Date of eligibility.

67:46:11:13 Payment limits.

67:46:11:01. Definitions. Terms defined in § 67:16:01:01 have the same meaning when used in this chapter. In addition, terms used in this chapter mean:

(1) "BIA," the bureau of Indian affairs;

(2) "Coinsurance," that portion of the medical costs allowable but not payable by Medicare and for which the individual is responsible;

(3) "Deductible," the initial amount of allowable Medicare costs paid by the individual before Medicare begins paying;

(4) "Medicare," the federal health insurance program available through the social security administration for certain disabled individuals and for individuals 65 years of age or older;

(5) "OCSE," the office of child support enforcement within the department of social services;

(6) "Part A," insurance available through the Medicare program to help pay for medically necessary hospice or home health care or care in a hospital or skilled nursing facility;

(7) "Part B," insurance available through the Medicare program to help pay for medically necessary physician services, outpatient hospital services, and medical supplies;

(8) "Qualifying Individual" or "QI," a person who meets the requirements of this chapter and who is not otherwise eligible for Medicaid benefits and for whom the state pays the Part B Medicare premium;

(9) "Qualified Medicare beneficiary" or "QMB," a person who meets the requirements of this chapter and for whom the state pays the Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments;

(10) "SCORE," the service corps of retired executives;

(11) "Special low-income Medicare beneficiary" or "SLMB," a person who meets the requirements of this chapter and for whom the state pays the Part B Medicare premium; and

(12) "VISTA," the volunteers in service to America.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:01, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:02. Long-term care requirements applicable to QI, QMB and SLMB. All provisions of chapters 67:46:02 to 67:46:05, inclusive, and 67:46:08 apply to QI, QMB and SLMB applicants and recipients unless otherwise specified in this chapter.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:02, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:03. Income eligibility. After the $20 disregard, income for a QMB individual may not exceed 100 percent of the federal poverty level established in § 67:11:01:03. If the individual's countable income is 100 percent of the federal poverty level or less and the individual is married and living with a spouse, the income of the spouse must be considered. If their combined countable income exceeds 100 percent of the federal poverty level for two individuals, the individual is ineligible.

After the $20 disregard, the countable income for a SLMB individual must exceed 100 percent of the federal poverty level and be less than 120 percent of the federal poverty level. If the individual's countable income is less than 120 percent of the federal poverty level and the individual is married and living with a spouse, the income of the spouse must be considered. If their combined countable income is equal to or greater than 120 percent of the federal poverty level for two individuals, the individual is ineligible.

After the $20 disregard, the countable income for a QI individual must be at least 120 percent of the federal poverty level and be less than 135 percent of the federal poverty level. If the individual's countable income is less than 135 percent of the federal poverty level and the individual is married and living with a spouse, the income of the spouse must be considered. If their combined countable income is equal to or greater than 135 percent of the federal poverty level for two individuals, the individual is ineligible.

Source: 15 SDR 171, effective May 15, 1989; 16 SDR 203, effective May 27, 1990; transferred from § 67:16:30:03, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 20 SDR 92, effective December 21, 1993; 21 SDR 162, effective March 23, 1995; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Cross-Reference: Income disregard, § 67:46:11:09.

67:46:11:04. Deduction from income for dependent child. Repealed.

Source: 15 SDR 171, effective May 15, 1989; 16 SDR 203, effective May 27, 1990; transferred from § 67:16:30:04, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 21 SDR 162, effective March 23, 1995; repealed, 41 SDR 93, effective December 3, 2014.

67:46:11:05. Deduction for court-ordered support or support enforced by OCSE. The department shall deduct from the ineligible spouse's income that portion of the income paid under court order or enforced by OCSE for the support of another person who is not in the household.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:05, effective August 23, 1992.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:06. Items not considered income when determining QI, QMB or SLMB eligibility. In addition to those items contained in § 67:46:04:03, the following items are not considered income when determining QI, QMB or SLMB eligibility:

(1) Assistance based on need provided by a local government or nongovernmental agency, such as Catholic Charities, county assistance, or assistance from the Salvation Army;

(2) Replacement of resources in cash or in kind because of loss, damage, or theft of property;

(3) Home energy assistance;

(4) Home produce for personal use;

(5) Foster care payments made to a foster care provider;

(6) Grants or loans to undergraduate students for educational purposes which are insured by the United States secretary of education;

(7) Housing assistance from housing and urban development or farmer's home administration;

(8) Credit life or credit disability insurance payments on loans, installment purchases, and similar items in the event of death or disability;

(9) Money borrowed;

(10) Money received as repayment on the principal of a loan;

(11) Reimbursements for expenses of obtaining income such as per diem payments and mileage;

(12) United States department of agriculture food commodities, the value of coupon allotments from government agencies and, for an individual age 60 or over, the value of meals received at a center or the value of meals delivered to the individual's home;

(13) Any benefits received under the provisions of the Older Americans Act of 1965, except wages or salary;

(14) Payments to volunteers under the Domestic Volunteer Service Act of 1973, such as from SCORE, VISTA, or the foster grandparent program; and

(15) Indian judgment funds distributed on a per capita basis.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:06, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:07. Income from self-employment. The net income from self-employment is considered earned income. Net income is the taxable income declared on the individual's most recent income tax return. If a tax return was not filed or was filed and indicated no self-employment, the net income is as established on either a profit and loss statement or on some other business record for the tax year.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:07, effective August 23, 1992.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:08. Deduction from earned income. A deduction of $65 plus one-half of the remainder is deducted from the total monthly earned income. If the individual is living with a spouse, the earned income deduction applies to the couple's total earned income.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:08, effective August 23, 1992.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:09. Income disregard. The department shall disregard $20 a month from the applicant's or recipient's unearned income unless the income is from a source based on need, such as certain veterans' benefits, TANF, or BIA general assistance. If unearned income is less than $20, the difference shall be deducted from the applicant's or recipient's gross earned income before applying the earned income disregard provided in § 67:46:11:06. If the individual is living with the individual's spouse, the $20 deduction applies to the couple's combined income.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:09, effective August 23, 1992; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:10. Resource limit. Repealed .

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:10, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 7, effective July 29, 2014; 41 SDR 93, effective December 3, 2014; 41 SDR 218, effective June 30, 2015; 44 SDR 94, effective December 4, 2017; 45 SDR 82, effective December 10, 2018.

67:46:11:11. Disposal of resources. The value of resources disposed of and no longer owned by the individual are not considered. The provisions of §§ 67:46:05:06 and 67:46:05:07 do not apply.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:11, effective August 23, 1992.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:12. Date of eligibility. Benefits for individuals eligible for QMB begin with the month after the month in which the individual is determined eligible. Eligibility starting dates outlined in § 67:46:01:03 do not apply.

Benefits for individuals eligible for SLMB or QI begin with the first day of the month of application. Eligibility may begin as early as the first day of the third month prior to the month of application if all eligibility criteria are met.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:12, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

67:46:11:13. Payment limits. If an individual is eligible for QMB, payment is limited to Medicare premiums, deductibles, coinsurance, and copayment for Part A and Part B of Medicare.

If an individual is eligible for SLMB, payment is limited to the Part B Medicare premium.

If an individual is eligible for QI, payment is limited to the Part B Medicare premium. The department may discontinue services provided under the provisions of this chapter if the department exhausts its financial resources for providing the services.

Source: 15 SDR 171, effective May 15, 1989; transferred from § 67:16:30:13, effective August 23, 1992; 19 SDR 141, effective March 25, 1993; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.