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Medicare Savings Programs Manual

WG-1 Forming Eligibility Groups; Examples

Updated 9/17/19

Example 1 - Standard Living Arrangement

Single Person

George has SSI and Medicare, lives in his own home.

George is included in all of the QMB eligibility groups and he is assumed eligible for QMB and OSIPM.


Coding:

Example 2 - Standard Living Arrangement

Single Person

Fred has SSD and Medicare, lives in his own home. His income is higher than the OSIPM standard and lower than the QMB standard. 

Fred is included in all of the QMB and OSIPM eligibility groups.

Coding:

Example 3 - Standard Living Arrangement

Couple - One person eligible for QMB

Sam and Martha are married and live at home with no services. Sam is 65, receives Social Security and Medicare. Martha is 60 and has a small pension but no Social Security or Medicare.

QMB groups:

Count both Martha and Sam’s income (both in Financial group) and use the two-person need standard (both are in the Need group). Sam is the only one in the benefit group because he is the only one who receives Medicare (a non-financial requirement).

Coding:

Example 4 - Non-standard Living Arrangement

Couple - One person receiving in-home services and the other receives no services

Joe and Kelly are married and live at home. Joe is 65, receives Social Security and Medicare. Kelly is 60 and has a small pension but no Social Security or Medicare. Joe starts receiving in-home waivered services. Their income level is 117% FPL for a couple.

SMB groups:

Eligibility - You will count both Kelly and Joe’s income (both in Financial group) and use the two-person need standard (both in Need group). Joe is the only one in Benefit group because he is the only one who receives Medicare (a non-financial requirement).

Since Joe is in a nonstandard living situation, he would be the only one in the OSIPM eligibility groups (not counting Kelly's income and using a one-person need standard).

Coding - While the mainframe does not calculate liability correctly when we include both spouses' income on the case, the pay-in system does not use the mainframe to calculate liability, so we can include Kelly and her income on the case.  Doing this will allow CMS to calculate Joe’s SMB eligibility correctly. Note: If Kelly was also receiving MSP benefits, she should have a separate case with Joe as a need-group member only. While community spouses can be added to in-home service cases as need group members, they should not be receiving benefits on the institutionalized spouse's medical case.

Coding

Example 5 - Nonstandard Living Arrangement

Couple - both in a community based care, both receiving Medicare

John and Sally are married and live in the ACME Foster Home. John is 65, receives Social Security and Medicare. Sally is 60 and also has Medicare and Social Security. They both have service needs which meet the service need rule. Their combined income is 119% FPL for a couple.

SMB Groups:

They are each alone in the OSIPM eligibility groups.

Whenever a client is in a community based facility they must be coded as a household group of one, otherwise the 512 will not calculate liability correctly.  Each spouse’s MSP eligibility must be manually calculated and narrated in Oregon ACCESS.

Coding on each case:

Example 6 - Standard Living Arrangement

Children under 21 in the household

Portlandia lives with her two minor children, Oswego and Boring. She receives a retirement pension and Medicare. Her pension is higher than the one-person QMB standard, but below the three-person standard.

All groups (except Benefit) will include Portlandia and her children, because she chooses to include them in order to be eligible.

Coding:

Example 7 - Non-standard Living Arrangement

Couple - One member in community based care and the other at home, both receiving Medicare and Medicaid.

Greg and Sarah are married. Greg lives in the ACME Foster Home while Sarah lives in their home. Greg is 65, receives Social Security and Medicare. Sarah is 60 and has a small pension, Social Security and Medicare. She has no OSIPM eligibility. His income is 140% FPL and hers is 130% FPL.

Groups: there are two sets of groups with Greg and Sarah each having individual HH; Filing; Financial; Need and Benefit groups for each program. 

Coding on his case:

Coding on her case:

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