*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: June 1, 2011 |
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03.35.15 - Qualified Individuals (QI) |
Archived: June 1, 2016 (Previous Versions) |
People may be eligible for Qualified Individual (QI) benefits if they meet the requirements of Qualified Medicare Beneficiary (QMB) or Service Limited Medicare Beneficiary (SLMB), but have excess income for those programs.
To be eligible for QI, people must:
l Be enrolled in or are eligible to enroll in Medicare Part A with or without a premium.
l Have income in excess of the QMB limit of 100% FPG and the SLMB limit of 120% FPG, but within the QI limits described below.
People may apply for QI to cover the Part B premium payment even if they choose not to take Part A.
See Medicare for more information about eligibility criteria for Medicare. See Medicare Savings Programs for more information about eligibility for Medicare Savings Programs.
Eligibility factors and links to standard program guidelines are provided below.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Application Process (standard guidelines)
QI benefits are funded through a capped federal entitlement. Enroll eligible applicants on a first-come, first-served basis in the order in which they apply. DHS will notify counties if the QI allocation is exhausted for a particular year.
QI benefits are available for the three months before the month of application, as well as for the application month and ongoing months.
Renewals (standard guidelines)
Do not require six-month renewals for QI enrollees who meet any of the exceptions noted in six-month renewals.
Verify enrollment in or eligibility to enroll in Medicare Part A.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
U.S. citizens who are enrolled in or eligible to enroll in Medicare are not required to provide citizenship or identity documentation.
For noncitizens, follow standard guidelines for federally funded MA.
Residency (standard guidelines)
Follow standard MA guidelines.
DHS pays Medicare Part B premiums through the Medicare buy-in for people who are enrolled in QI.
Household Composition (standard guidelines)
Follow standard MA guidelines in Determining Household Size for MA to determine which household members to count in the household size when determining QI eligibility for a person who is not requesting Elderly Waiver (EW), but has a spouse who is on EW. However, do not count the person’s spouse in the household size if the spouse is on EW. See Exceptions to MA Household Size.
Example:
Jack is on EW and is eligible for Medicare. He lives with his wife Wendy and their 17-year-old daughter Mary. Wendy is eligible for Medicare and is not requesting EW.
Action:
Determine Wendy’s eligibility for QI using a household size of two (Wendy and Mary).
Use Method B for income and assets.
Asset Guidelines (standard guidelines)
Asset limit is:
l $10,000 for a household of one.
l $18,000 for a household of two or more.
Income Guidelines (standard guidelines)
Income must be greater than 120% FPG but less than or equal to 135% FPG. Income eligibility is determined on a monthly basis. QI does not have a six month or annual income standard.
Example:
Myrtle is paid bi-weekly through her employer. In December, she will receive three paychecks and her income will be higher than the 135% FPG standard.
Action:
Myrtle’s total net income exceeds the standard in December. She is ineligible for QI in December.
In addition to allowing the income deductions and disregards for the applicable age 65 or older, blind, or disabled status, apply the standard $20 disregard when determining QI eligibility.
Apply the standard $20 disregard in addition to allowing the income deductions and disregards for the applicable age 65 or older, blind, or disabled status basis when determining QI eligibility.
Disregard RSDI cost-of-living adjustments (COLA) for January through June of each year.
Exclude Aid and Attendance benefits and Allowances for Unusual Medical Expenses received from the Veteran’s Administration.
Spenddowns (standard guidelines)
QI has no spenddown provisions.
Example:
Bud’s income is 140% FPG. He is ineligible for QI even if his medical expenses would allow him to spend down to 135% FPG.
The benefit of the QI program is payment of the Medicare Part B premium.
Service Delivery (Prepaid MHCP Manual)
People who receive only QI benefits are excluded from managed care enrollment.
Not applicable.
Eligibility for QI ends if the enrollee loses Medicare eligibility, has excess income or assets, or becomes otherwise eligible for MA.
Relationship to Other Groups/Bases (standard guidelines)
See Medicare Savings Programs for general information about the relationship between MSPs and other program eligibility.
People cannot be concurrently eligible for QI and any of the following programs:
l MinnesotaCare.
l Medical Assistance (MA), including MA-EPD.
Exception: MA and QI may overlap in the retroactive eligibility circumstances noted below.
l Qualified Medicare Beneficiary (QMB).
l Service Limited Medicare Beneficiary (SLMB).
MA and QI may overlap when a person receiving QI benefits requests retroactive MA. If MA eligibility will continue beyond the month in which eligibility is approved, close QI for the first month for which you can give ten-day notice.
Example:
John is eligible for QI benefits. On September 12, he applies for MA and requests coverage retroactive to July. On October 15, eligibility is determined and John is eligible for MA effective July 1 and continuing.
Action:
Close QI effective November 1. If John qualifies for QMB or SLMB, open whichever is appropriate.
Determine whether the applicant or enrollee is eligible for QI benefits if he or she is ineligible for MA due to excess income and the inability to meet a spenddown. Determine QI eligibility in any month an enrollee does not meet his or her spenddown when enrolled in MA with a manual monthly spenddown.
Example:
Arthur applies for MA on April 2 but is ineligible due to excess income. He has not incurred enough medical expenses to meet his spenddown. Arthur has been certified disabled by Social Security and is enrolled in Medicare. His countable income is $1,185 per month, which exceeds the SLMB income limit of 120% FPG but is less than the QI limit of 135% FPG.
Action:
Approve QI eligibility for Arthur. His income and assets are within the QI limits.
Example:
Mabel, age 67, is enrolled in MA with a manual monthly spenddown. Her income exceeds 120% FPG but is less than 135% FPG. Mabel met her spenddown for March and MA was approved for the month of March. Mabel provides her April income and medical expenses in May. She did not meet her spenddown for April. Mabel’s income is within the QI income limit and she is a Medicare beneficiary.
Action:
Approve QI eligibility for Mabel for April. Open QI effective April 1 and close QI effective May 1. Approve QI eligibility effective May 1 and close QI effective June 1 if Mabel does not meet her spenddown again in May, but her income remains within the QI income limit. Continue to determine QI eligibility for each month of her certification period.