State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

32.1 Medicare Savings Programs

 

32.1.1 Medicare Savings Programs Introduction

Medicare is the health insurance program administered by CMS for people 65 years old, people determined disabled for two years or more, or people with end-stage renal disease (permanent kidney failure requiring dialysis or transplant). People who receive Medicare are referred to as Medicare beneficiaries.

 

Medicare is divided into four types of health coverage:  

• Hospitalization insurance (Part A), which pays hospital bills and certain skilled nursing facility, home health care, and hospice expenses.  
• Medical insurance (Part B), which pays doctor bills and certain other charges.  
• Medicare Advantage (Part C), which allows private health insurance companies to provide Medicare benefits.
• Drug insurance (Part D), which pays for prescription drug charges.

 

Medicare charges monthly premiums, and Medicare beneficiaries are responsible for deductibles and coinsurance payments to providers. These out-of-pocket charges are generally referred to as Medicare cost-sharing.  

 

Wisconsin Medicaid may pay some or all of the member’s Medicare cost-sharing for certain Medicare beneficiaries participating in the following programs:

• QMB
• SLMB
• SLMB+
• QDWI

 

These programs are called Medicare Savings Programs (MSP). (They may also be referred to as Medicare Premium Assistance or Medicare Buy-In programs.)  

 

When determining eligibility for MSP, IM workers should use the same rules for determining financial eligibility as are used for Medicaid with the exception of using the MSP asset limits in Section 32.6 Medicare Savings Programs Asset Limits and the MSP income limits in Section 39.5 Federal Poverty Level Table. Nonfinancial eligibility is available as follows:

• For QMB, see Section 32.2 Qualified Medicare Beneficiary.
• For SLMB, see Section 32.3 Specified Low-Income Medicare Beneficiary.
• For SLMB+, see Section 32.4 Specified Low-Income Medicare Beneficiary Plus.
• For QDWI, see Section 32.5 Qualified Disabled and Working Individual.

 

QMB members will receive a ForwardHealth card even if the member is not eligible for any other subprograms of Medicaid since Medicaid pays the Medicare copayments and deductibles for members enrolled in QMB.

32.1.2 Medicare Savings Programs Fiscal Test Group

The FTG size is two when a couple is living together in the community, unless one of the spouses is an SSI recipient. If one spouse is applying for MSP and the other spouse is an SSI recipient, the SSI recipient spouse is not included in the other spouse’s FTG. If both spouses are living in the same nursing home, each person is an individual FTG.

32.1.3 Medicare Savings Programs Benefits

• QMB: Medicaid pays Medicare Part A and B premiums and Medicare deductibles, copayments, and coinsurance.
• SLMB: Medicaid pays Medicare Part B premiums.
• SLMB+: Medicaid pays Medicare Part B premiums.
• QDWI: Medicaid pays Medicare Part A premiums.

32.1.4 Low Income Subsidy Requests

See Section 2.6.4 Low Income Subsidy Program of Medicare Savings Programs for information on LIS Requests for MSP .

32.1.5 Part B Enrollment Via the Medicare Savings Programs Buy-In Program

Members receiving Medicare Part A coverage who chose not to enroll in Part B may be eligible to enroll in Part B via the MSP process with the state. The MSP eligibility should be determined in CWW. If the member is eligible for MSP, the worker must contact the ForwardHealth Medicare buy-in analyst by phone at 608-224-6126 or by filling out a Medicaid/BadgerCare Plus Eligibility Certification form (F-10110) stating when the member will begin their Medicare buy-in eligibility. The Medicare buy-in analyst will create a manual transaction to send to CMS with the appropriate MSP information. Once CMS processes the record, the member should be enrolled into Part B with coverage beginning the first month of MSP eligibility.

 

Example 1:  In January, the member applies for QMB benefits and is only receiving Part A Coverage. The case worker determines the member qualifies for QMB starting February. After the confirmation is done in CARES in January, the worker contacts the ForwardHealth Medicare buy-in analyst to report the enrollment. The buy-in analyst creates a transaction with the QMB information. This transaction is sent to CMS in February.     Once CMS processes the record and bills the state, the member will show Part B coverage starting in February.

 

 

 

This page last updated in Release Number: 18-01

Release Date: 04/13/2018

Effective Date: 04/13/2018

 

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030