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 the Center for Medicare and Medicaid Services (CMS); 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 Disabled Workers (Oregon calls these QMB-DWs or just DWs and they are coded as QDWI in ONE) 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. To be eligible for QMB, individuals must be receiving Medicare Part A or be conditionally enrolled through ODHS. If a person is determined eligible for QMB they will have their Medicare Part B premiums paid as well as co-insurance and deductibles for Medicare covered services, up to the Department’s fee schedule. QMB will pay the Part A premium for individuals who do not have free Part A (also referred to as “uninsured”). This program does not cover any Part D costs. The adjusted income limit for QMB is up to and including 100% of the Federal Poverty level.
If it appears that a individual should be eligible for Medicare Part A, but they are not receiving it, follow the instructions in MSP.D.3. 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 MSP WG.4 for more information on conditional enrollment.
SMB. To qualify for SMB a person must be receiving Medicare Part A. This includes people who have to pay a premium for the coverage. Eligible individuals receiving stand-alone SMB benefits will not receive a medical card. Eligibility is limited to individuals 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 recipient’s eligibility starts the first of the month in which their eligibility is determined and verified.
When an individual is approved for retroactive SMB coverage, they will receive a reimbursement check for the past (up to 3 months) premiums that are covered. Let the individual 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 recipients.
SMF. To qualify for SMF a person must be receiving Medicare Part A. Individuals who are receiving any other Medicaid program offered by the state, including OSIPM and all MAGI programs, are not eligible for SMF. Eligibility is limited to individuals whose income is equal to 120% and up to 135% of the federal poverty level. Coverage is limited to payment of their Medicare Part B premium. An SMF recipient’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 recipients, so the program must close when the allocation has been spent.
The department receives 100% federal matching funds for SMF recipients.
When an individual is approved for retroactive SMF coverage, they will receive a reimbursement check for the past (up to 3 months) premiums that are covered. Let the individual know that they will be receiving this check in about 3 months. They do not need to report it.DW. DW has the highest allowable income for a Medicare Savings Program at 200% of the Federal Poverty level. To be eligible for 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 and not qualify for any other Medicaid program. The Social Security Administration makes the decision as to whether or not an individual meets the eligibility criteria to be a qualified disabled worker. To meet the criteria the individual 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. DW pays for the Medicare Part A premium only – there is no Part B buy-in for these individuals. DW recipients may be eligible for retroactive medical coverage, but they can not be eligible for DW and OSIPM at the same time.
Because every individual eligible for DW would also be eligible for OSIPM-EPD (even if they choose not to receive it), they cannot qualify for DW. That is why we do not have any DW recipients in Oregon.
Information about Medicare Buy-In
Buy-in refers to the process of the state paying an individual’s Medicare premiums. Oregon sets up buy-in for individuals receiving QMB, SMB, or SMF benefits.
In addition, the State of Oregon must pay the Part B premium for everyone who receives Medicare and full Medicaid benefits (OHP Plus). This is established in Oregon’s Medicaid State Plan that is filed with CMS.* If the individual also qualifies for one of two MSPs that pay the Part B premium and can coexist with OHP Plus (QMB and SMB), then the state will be reimbursed by CMS for around 2/3 of the Part B premium. Those who are over income for QMB and SMB are categorized as State Buy-In (SBI), meaning the state will pay the Part B premium but not receive reimbursement from CMS. You will see this most commonly with Employed Persons with Disabilities (OSIPMEPD) and individuals receiving long-term care service benefits. We do this because Medicare will always be billed before Medicaid, so paying the Part B premium to keep Medicaid clientindividuals enrolled in Medicare is a good investment.
*We do allow some LTC recipients to pay the Part B premium themselves and instead receive an equivalent reduction of their service liability. This is called Client Buy-In (CBI). See the MSP WG 2 and Patient Liability Manual Update QRG for more information about how CBI works.
Qualified Medicare Beneficiary
QMB-BAS – used in OARs, training materials, FSM, and worker guides (unique to Oregon)
QMB – used in OARs to refer to all MSPs (“QMB programs”), training materials, worker guides, federal rules, and other states’ rules and policy manuals
QMBP – TOA code in ONE
MED – benefit plan in MMIS that refers to QMB-only
QMM – benefit plan in MMIS that refers to OHP Plus and QMB
Specified Low-Income Medicare Beneficiary
QMB-SMB – used in OARs, training materials, FSM, and worker guides (unique to Oregon)
SLMB – TOA code in ONE, federal rules, all other states’ rules and policy manuals
SMB – benefit plan code in MMIS, used in some training materials and worker guides
QMB-SMF – used in OARs, training materials, FSM, and worker guides (unique to Oregon)
QSMF – TOA code in ONE
SMF – benefit plan code in MMIS, used in some training materials and worker guides
QI-1 or QI – federal rules, all other states’ rules and policy manuals