8.07 Medicare savings programs

In general An individual is eligible for Medicaid payment of certain Medicare costs if they meet one of the criteria specified in paragraph (b) of this subsection. An individual eligible for one of the Medicare savings programs coverage groups identified in paragraph (b) below may also be eligible for the full range of Medicaid covered services if they also meet the requirements for one of the categorically-needy or medically-needy coverage groups. An individual may not spend down income to meet the financial eligibility tests for these coverage groups. For purposes of determining income eligibility for these coverage groups, an individual’s family size is as follows: (i) Effective April 1, 2026, an individual’s family size includes the individual, their spouse who is living in the same household, if any, and anyone who is related to the individual by blood, adoption or marriage if they are living in the same household and are dependent on the individual or the individual’s spouse for at least one-half of their financial support. 40 (ii) Through March 31, 2026, an individual’s family size is the same as the individual’s Medicaid group (as defined in § 29.04) for purposes of MABD eligibility. Coverage groups Qualified Medicare Beneficiaries (QMB) 41 (i) An individual is eligible for Medicaid payment of their Medicare Part A and Part B premiums, deductibles, and coinsurance, or coverage of premiums and cost sharing related to enrollment in Medicare Part B for coverage of immunosuppressive drugs, if the individual is a member of a Medicaid group (as defined in § 29.04) with MABD income at or below 150 percent of the FPL for their applicable family size as defined in subparagraph (a)(4) above; and Entitled to Medicare Part A with or without a premium (but not entitled solely because they are eligible to enroll under § 1818A of the Act, which provides that certain working disabled individuals may enroll for premium Part A) for purposes of Medicaid payment of their Medicare Part A and Part B premiums, deductibles, and coinsurance as described in (i) above; or Enrolled under Medicare Part B for coverage of immunosuppressive drugs for purposes of coverage of premiums and cost sharing related to enrollment in Medicare Part B for coverage of immunosuppressive drugs as described in (i) above. (ii) There is no resource test for this group and any dividend or interest income earned on resources is disregarded. (iii) Benefits become effective on the first day of the calendar month immediately following the month in which the individual is determined to be eligible. (iv) Retroactive eligibility is not available. (v) Special income disregard for an individual who is receiving a monthly insurance benefit under Title II of the Social Security Act. If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit payable as a result of a Title II cost-of- living adjustment (COLA) is not counted as income until the beginning of the second month following the month of publication of the revised annual FPL. For individuals who have Title II income, the new poverty levels are effective beginning with the month after the last month for which COLAs are disregarded. For individuals without Title II income, the new poverty levels are 40 42 CFR § 435.601(e). 41 42 CFR § 435.123. effective no later than the date of publication in the Federal Register. 42 [Reserved] Qualified Individuals (QI-1) 43 (i) An individual is eligible for Medicaid payment of their Medicare Part B premiums if the individual is entitled to Medicare Part A, or coverage of the Part B premium related to enrollment in Medicare Part B for coverage of immunosuppressive drugs if the individual is enrolled under Medicare Part B for coverage of immunosuppressive drugs, if the individual: Would be eligible for benefits as a QMB, except for income; Is a member of a Medicaid group (as defined in § 29.04) with MABD income that is greater than 150 percent but less than 202 percent of the FPL for their applicable family size as defined in subparagraph (a)(4) above; and Does not receive other federally-funded medical assistance (except for coverage for excluded drug classes under Part D when the individual is enrolled in Part D). (ii) There is no resource test for this group and any dividend or interest income earned on resources is disregarded. (iii) Benefits under this provision become effective on the first day of the month within which an application is received by AHS provided the individual is determined to be eligible for that month. (iv) Retroactive eligibility (of up to three calendar months prior to the month an application is received by AHS) applies if: The individual met all QI-1 eligibility criteria in the retroactive period; and The retroactive period is no earlier than January 1 of that calendar year. 44 (v) The benefit period ends in December of each calendar year. An individual requesting this coverage must reapply each calendar year. Qualified Disabled and Working Individuals (QDWI) (i) An individual is eligible for Medicaid payment of their Medicare Part A premiums if the individual: Has lost their premium-free Part A Medicare benefits based on disability because they returned 42 Vermont gives effect to this rule by estimating the new year’s FPL levels in January of each year. Vermont applies the new FPL against the new income during a January eligibility desk review. By using the adjusted FPLs, Vermont effectively disregards the title II COLA and ensures that the income increase has no negative effect on eligibility. 43 42 CFR § 435.125. 44 CMS State Medicaid Manual, § 3492. to work; Is disabled and under the age of 65; Is a member of a Medicaid group (as defined in § 29.04) with MABD income at or below 200 percent of the FPL for their applicable family size as defined in subparagraph (a)(4) above; Is a member of a Medicaid group with MABD resources at or below twice the MABD resource limit; and Is not otherwise eligible for Medicaid. (ii) Benefits become effective on either the date of application or the date on which all eligibility criteria are met, whichever is later. (iii) Benefits for a retroactive period of up to three months prior to that effective date may be granted, provided that the individual meets all eligibility criteria during the retroactive period. Special Medicaid groups (01/01/2025, GCR 24-075)