Starting in 1988, the Federal Government created a group of programs called the Medicare Savings Programs. These programs provide Medicaid benefits that are related to the receipt of Medicare benefits.
Medicare is a federal medical benefits program that is administered by CMS (Center for Medicare and Medicaid Services) which contracts with intermediaries such as Blue Cross or Aetna; it is not administered by the state like Medicaid.
There are three types of Medicare:
Some recipients are required to pay a premium for Medicare Part A and there is always a premium for Medicare Part B.
Currently there are three Medicare Savings Programs in Oregon:
There is another group, the QMB Disabled Workers QMB-DWs who can have income up to 200% of the FPL. However, there aren’t any DWs in Oregon currently and there won’t be as long as OSIPM-EPD exists as a program
QMB-BAS. To be eligible for QMB-BAS, clients must be receiving Medicare Part A or be conditionally enrolled through DHS. If a person is determined eligible for QMB-BAS they will have their Medicare Part A and Part B premiums paid as well as co-insurance and deductibles for Medicare covered services, up to the Department’s fee schedule. This program does not cover any Part D costs. The adjusted income limit for QMB-BAS is up to and including 100% of the Federal Poverty level.
If it appears that a client should be eligible for Medicare Part A, but they are not receiving it, contact the Medicare Buy-In Unit. All individuals who are at or under 100% of FPL are considered mandatory enrollees if they are eligible for Medicare Part A and aren’t getting it only because their premiums aren’t being paid. We need to do a conditional enrollment with SSA for these people. See QMB WG.4 for more information on conditional enrollment.
QMB-SMB. To qualify for QMB-SMB a person must be receiving Medicare Part A. This includes people who have to pay a premium for the coverage. QMB-SMB only clients will not receive a medical card. Eligibility is limited to clients whose income is above 100 and below 120% of the federal poverty level. Coverage is limited to payment of their Medicare Part B premium. An SMB client’s eligibility starts the first of the month in which their eligibility is determined and verified.
When a client is picked up by the Buy-In unit for retroactive SMB coverage, they will receive a reimbursement check for the past (up to 3 months) premiums that are covered. Let your client know that they will be receiving this check in about 3 months. They do not need to report it.
The department receives the regular Medicaid program federal matching funds for SMB clients.
QMB-SMF. (QI-1)- To qualify for QMB-SMF a person must be receiving Medicare Part A but they cannot be residing in an institution (nursing facility, hospital or ICF/MR). Eligibility is limited to clients whose income is equal to 120 up to 135% of the federal poverty level. Coverage is limited to payment of their Medicare Part B premium. An SMF client’s eligibility starts the first of the month in which their eligibility is determined and verified. The department receives a fixed allocation from the Federal Government to cover SMF clients, so the program must close when the allocation has been spent.
The department receives 100% federal matching funds for SMF clients.QMB-DW. QMB-DW has the highest allowable income for a Medicare Savings Program at 200% of the Federal Poverty level. To be eligible for QMB-DW, (disabled worker) a person must be eligible for Medicare Part A as a qualified disabled worker under Section 1818 (A) of the Social Security Act. The Social Security Administration makes the decision as to whether or not a client meets the eligibility criteria to be a qualified disabled worker. To meet the criteria the client must be under age 65 and have lost eligibility for Social Security disability benefits because they have become gainfully employed, however they can continue to receive Medicare Part A if they pay a premium. QMB-DW pays for the Medicare Part A premium only. QMB-DW clients may be eligible for retroactive medical coverage, but they can not be eligible for QMB-DW and OSIPM at the same time.