Effective Date: February 1, 2023

Previous Policy

What are the Medicare Cost-Sharing Programs?

The Medicare Cost-Sharing Programs help Medicare beneficiaries with their Medicare costs. These programs may pay the Medicare Part A, Part B and Part B-ID premiums, co-payments and deductibles. Individuals receiving these programs are eligible for the Medicare Low Income Subsidy to help pay the cost of their prescription drugs. Depending on the Part D plan they choose, they will have no premium or a small monthly premium, no yearly deductibles, no coverage gap and reduced co-payments. See section 705 for the rules on retroactive coverage. There are four programs:

Qualified Medicare Beneficiaries (QMB) - This program pays the Part B and Part B-ID Medicare premium, Medicare co-payments and deductibles. It may pay the Part A premium for some members.

Specified Low-Income Medicare Beneficiaries (SLMB) – This program pays the Part B and Part B-ID Medicare Premium.

Qualifying Individuals (QI) – This program pays the Part B and Part B-ID Medicare premium.

Qualified Disabled Working Individual (QDWI) – This program pays the Part A Medicare premium. (The federal Medicaid agency identifies these individuals. Contact the Health Program Specialist if you have questions.)

Refer to section 223-2 for a description of the Medicare premium buy-in process.

How Does Someone Apply?

An application for medical assistance is also an application for Medicare Cost Sharing programs if the person is entitled to Medicare Part A. For the Medicare Cost Sharing Programs Part B-ID, enrollment in Part A is not required. Screen all applications to decide if the individual is eligible for a Medicare Cost-Sharing program.

Effective January 1, 2010, Social Security will send electronic application data to states. This data is about individuals who have applied for a Medicare Part D Low-Income Subsidy. The electronic data is an application for the Medicare Cost Sharing programs. It is not an application for Medicaid. Individuals will need to complete a separate application with the Dept. of Workforce Services if they want to apply for Medicaid. See Sec. 320-1 , D.

When an ongoing member is about to become eligible for Medicare, decide if the member is eligible for a Medicare Cost-Sharing program. Do this during case reviews, too. A new application is not required for an open case.