A. The specific
eligibility requirements and benefits coverage groups included in the MPPP
pathway are as follows:
1. Qualified Medicare
Beneficiaries (QMBs) without other Medicaid (QMB Only) - Financial assistance
in this group is provided to beneficiaries who are eligible for or enrolled in
Medicare Part A, have countable income of one hundred percent (100%) of FPL or
less and resources that do not exceed the amounts set annually by the Federal
government (see §1.6.5 of this Part). For
partial dual eligible QMBs:
a. Medicaid makes
a direct payment to the Federal government for the Part A premium (if any), the
Part B premium, and provides payments for Medicare co-insurance and deductibles
as long as the total amount paid by Medicare does not exceed the amount
Medicaid allows for the service.
b.
Eligibility begins on the first (1st) day of the month after the application is
filed and all eligibility requirements are met.
c. Eligibility is renewable in twelve (12)
month periods.
d. Deeming rules do
not apply.
e. There is no
retroactive coverage.
2.
QMBs with Medicaid health coverage (QMB Plus) - Persons who qualify through
this pathway must be entitled to Medicare Part A, have countable income at or
below one hundred percent (100%) of the FPL, and resources at four thousand
dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a
couple. Beneficiaries eligible through this pathway are full dual eligible
beneficiaries and receive premium assistance and Medicaid health coverage.
Includes MN Medicaid beneficiaries. Access to Medicaid retroactive coverage,
continuing eligibility, and the full scope of Medicaid essential benefits is
available.
3. Specified Low-Income
Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These
individuals are entitled to Medicare Part A, have countable income of greater
than one hundred percent (100%) FPL, but less than one hundred twenty percent
(120%) FPL, resources within the federally defined limits, and are not
otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums
only.
a. Medicaid pays the Medicare Part B
premium to SSA.
b. Eligibility
begins on the first (1st) day of the month in which the application is filed
and all eligibility requirements are met.
c. Eligibility is authorized for a twelve
(12) month period and is renewable on that basis.
d. Deeming rules do not apply.
e. Retroactive coverage may be
available.
4. SLMBs with
Medicaid health coverage (SLMB Plus) - To be eligible through this pathway, a
person must be entitled to Medicare Part A, have countable income of greater
than one hundred percent (100%) FPL but less than one hundred twenty percent
(120%) FPL, and resources of no more than four thousand dollars ($4,000.00) for
an individual or six thousand dollars ($6,000.00) a couple. A person qualifies
for Medicaid through this pathway only if MN requirements are met. In addition
to full Medicaid essential benefits, the MPPP also pays the beneficiary's
Medicare Part B premiums, coinsurance, deductibles and copayments.
5. Medicaid pays the SSA. Community Medicaid
EAD general eligibility requirements govern access to Medicaid retroactive
coverage, continuing eligibility, and scope of coverage.
6. Qualified Disabled and Working Individuals
(QDWIs) - This pathway covers beneficiaries who lost their Medicare Part A
benefits due to their return to work. They must be eligible to purchase
Medicare Part A benefits, have countable income of two hundred percent (200%)
FPL or less and resources that do not exceed twice the limit for SSI
eligibility EAD limits of four thousand dollars ($4,000.00) for an individual
or six thousand dollars ($6,000.00) for a couple), and must not be otherwise
eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.
a. Medicaid makes a direct payment to the SSA
for the Part A premium;
b.
Eligibility begins the month in which all requirements are met, including
enrollment in Part A, and continues for a year unless or until changes in
employment result in resumption of Medicare without MPPP assistance.
7. Qualifying Individuals-1 (QI-1)
- To qualify for eligibility through this pathway, beneficiaries must be
entitled to Medicare Part A, have countable income of at least one hundred
twenty percent (120%) FPL, but less than one hundred thirty-five percent (135%)
FPL, resources that do not exceed the amounts set by the Federal government
(see §1.6.5 of this Part), and be
otherwise ineligible for Medicaid. Medicaid pays Medicare Part B premiums only.
Federal matching funds for members of this group is one hundred percent (100%)
and, as such, the availability of financial assistance through QI-1 eligibility
is contingent on Federal appropriations. For members of this group:
a. Medicaid makes a direct payment to the SSA
for the Part B premium.
b.
Eligibility begins the month in which the application is filed and all
requirements are met and ends on December thirty-first (31st) of the year in
which the application is filed.
c.
Cost-of-living increases in Title II benefits (COLAs), effective in January
each year, are disregarded in determining income eligibility through the month
following the month in which the annual Federal Poverty Guideline update is
published.
d. Deeming
applies.
e. Retroactive coverage
may be available. Retroactive eligibility (of up to three (3) calendar months
prior to application) applies if the individual met all QI eligibility criteria
in the retroactive period, and the retroactive period is no earlier than
January 1st of that calendar year.
8. MN and QMB (+) and SLMB (+) -
Participation in the MPPP may adversely affect the income eligibility of a
person seeking initial or continuing Medicaid health coverage through the MN
pathway. As the State pays some or all Medicare costs for MPPP participants,
these allowable health expenses cannot be counted toward a MN spenddown. This,
in turn, may make it difficult to obtain Medicaid health coverage for high
costs services that are covered only in part or not at all by Medicare. MPPP
enrollment may also affect other forms of Medicaid eligibility if it changes
the way income or resources are counted. An agency eligibility specialist
should be consulted by an applicant or beneficiary who is concerned that
enrolling in the MPPP will affect access to Medicaid health coverage.