Effective Date: June 1, 2025

Previous Policy

A. Recipients of Medicare Part A and Part B

1. To be eligible for a Medicare Cost-Sharing, an individual must be entitled to Part A Medicare.

2. For SLMB and QI the individual must be receiving Part A Medicare, including paying the Part A premium if one is required. To be eligible for QDWI, the individual must be eligible to receive Medicare Part A by paying a premium. See 320-5 for QDWI policy.

3. See 223-1 for information on who can receive Part A Medicare.

B. Recipients of Medicare Part B-ID

1. To be eligible for the Medicare Part B-ID Cost-Sharing Program, an individual must be entitled to Medicare Part B-ID only.

2. The individual cannot have any other health insurance which will cover immunosuppressant drugs as it will disqualify an individual. Other health insurance includes but are not limited to:

· Medicare Part A and/or Part B

· Medicaid

· Marketplace

· Employer Insurance

C. Non-Financial Requirements

To be eligible for Medicare Cost Sharing and the Medicare Part B-ID cost-sharing programs, individuals must meet the same non-financial rules that apply to Medicaid. These include:

1. Citizenship or resident non-citizen requirements. Remember that Medicare recipients meet the U.S. Citizenship requirements ( 205 ).

2. Utah residency ( 207 ).

3. Duty of Support requirements, if applicable ( 227 ).

4. TPL requirements for the Qualified Medicare Beneficiaries program, but not for SLMB, QI or Part B-ID cost-sharing program ( 225 ).

5. Social Security number ( 221 ).

6. Individuals ineligible for Medicaid because they reside in a public institution, or reside in an IMD and do not meet the residency requirements defined in 215-5 , are not eligible for Medicare Cost Sharing ( 215-5 ).

D. Income Limit

1. Countable income is compared to a percentage of the federal poverty level. Countable income cannot exceed the applicable income limits ( Table VII ).

2. The following percentages of poverty apply to these programs. Spenddown is not allowed.

QMB 100% FPL SLMB 120% FPL QI-1 135% FPL QDWI 200% FPL

3. For the Medicare cost-sharing programs and the Medicare Part B-ID cost-sharing program, follow the rules in section 443 to determine countable income. Use those rules for all Medicare cost-sharing individuals even if they receive SSI. Follow these rules even if the person is not disabled. This may include the following individuals:

a. Individuals diagnosed with end-stage renal failure.

b. Individuals determined disabled by the Railroad Retirement Board, who have received such disability benefits for 24 months, and who have not been determined disabled by Social Security or the MRB.

4. Not everyone under age 65 who receives Medicare meets Social Security's disability criteria. The person must have been determined disabled by either Social Security or the Medicaid Disability Board to receive Disability Medicaid. However, if the individual is eligible for Medicare Part A, the individual may qualify for a Cost-Sharing program.

E. Asset Limit

Determine assets the same as they are for the aged, blind, and disabled Medicaid programs. The resource limits are higher than those for Medicaid ( Table II ).

There is no transfer of asset penalty for the cost-sharing programs.

F. Applications from Social Security

1. Beginning January 1, 2010, Social Security (SSA) will transmit data electronically to states to use as an application for Medicare Cost-Sharing programs. This data is from applications SSA receives for Low-Income Medicare Subsidies. Treat this electronic data like any other application for the Medicare Cost-Sharing programs ( 703-4 ).

2. Process the data received the same as any other application for Medicare Cost-Sharing programs. The applicant must receive the application disclosures and rights and responsibilities information. The electronic transmission of data meets the signature requirements for the application.

3. If the individual wants to apply for Medicaid in addition to the Medicare Cost-Sharing programs, the individual must complete and sign a Medicaid application. If the individual applies for Medicaid, inform the individual of the estate recovery requirements for Medicaid recipients age 55+.

4. Estate recovery does not apply to Medicare Cost-Sharing Programs.