State of Wisconsin Department of Health Services

Release 24-03 December 18, 2024

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32.1 Medicare Beneficiaries Introduction

32.1.1 Medicare Savings Programs Introduction

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

Medicare is divided into four main 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 beneficiaries who are eligible for Medicare only due to end stage renal disease (ESRD) lose Medicare coverage 36 months after a kidney transplant. Beneficiaries who meet certain criteria, including not having any other health insurance coverage that covers immunosuppressive drugs, are able to qualify for continuous Medicare-covered immunosuppressive drugs through the Medicare Part B Immunosuppressive Drug (Part B-ID) benefit. The Part B-ID benefit covers only immunosuppressive drugs and no other items or services.

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:

• QMBQualified Medicare Beneficiary
• SLMBSpecified Low-Income Medicare Beneficiary
• SLMB+Specified Low-Income Medicare Beneficiary Plus
• QDWIQualified Disabled and Working Individual

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

A request for health care is also considered a request for MSP, unless the member specifically states otherwise. Any Medicaid applicant or member who has or becomes eligible for Medicare should have their eligibility determined for MSP without requiring an additional request.

When determining eligibility for MSP, the same rules for determining financial eligibility for Medicaid are used 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 FTGfiscal test group size is two when a couple is living together in the community, unless one of the spouses is an SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. 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, B, and B-ID premiums and Medicare deductibles, copayments, and coinsurance.
• SLMB: Medicaid pays Medicare Part B and B-ID premiums.
• SLMB+: Medicaid pays Medicare Part B and B-ID 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 LISLow Income Subsidy of Medicare Part D. This is also called "Extra Help" by the SSA. It helps people with limited resources pay for a portion of Part D costs. Requests for MSPMedicare Savings Programs. Assistance to help pay coinsurance, premiums, and deductibles for Medicare beneficiaries who are also one of these types of Medicaid recipients: QMB, SLMB, SLMB+, or QDWI. This has also been called "Medicare buyin," "buy in," or "Medicare Premium Assistance (MPA)." DHS is using the term "MSP" to refer to this type of assistance..

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

Members who are receiving Medicare Part A coverage, but who previously chose not to enroll in Part B, may be eligible to enroll in Part B outside of their usual enrollment periods via the MSP process with the state. See Process Help Section 61.2.1.3 Part B Enrollment Via MSP.

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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