In States Without Buy-In Agreement, March 31 is Deadline for Part A Enrollment and QMB Eligibility

In fifteen states, Medicare’s general enrollment period, January, February, and March, is a critical time for advocates to evaluate client eligibility for benefits under Medicare Savings Programs (MSP), in particular the Qualified Medicare Beneficiary (QMB) program.

These programs pay some of the costs of Medicare for qualified beneficiaries (the scope of benefits varies depending on the program and individual eligibility).  Participation is most important for seniors, such as low income senior immigrants, who lack the necessary work history otherwise needed to qualify for free Medicare hospital coverage. 

What is the Medicare general enrollment period? 

Medicare’s general enrollment period runs from January 1 through March 31, 2008.  A beneficiary who enrolls in Medicare Part A (hospital coverage) or Part B (outpatient medical coverage) during general enrollment will receive coverage beginning on July 1, 2008.  (Individuals just retiring or turning 65, or those just becoming eligible for Medicare disability benefits, are subject to separate enrollment period rules.) 

Which dual eligibles are affected by the general enrollment period?

Dual eligible individuals (those eligible for both Medicare and Medicaid (either full Medicaid or an MSP) can enroll in Part B at any time during the year in every state; therefore, the limited general enrollment period does not apply to duals who do not yet have Part B.  For Medicare Part A, however, year-round enrollment is only available to dual eligibles in states with “buy-in” agreements with the federal government.  Thirty-five states and the District of Columbia have buy-in agreements allowing dual eligibles to enroll in Part A any time during the year.  In the remaining fifteen states, dual eligibles and others can only enroll in Part A during the January-March quarter.  This includes the “conditional enrollment” QMB option described below. 

According to the SSA, the fifteen states without buy-in agreements are Alabama, Arizona, California, Colorado, Illinois, Kansas, Kentucky,  Missouri, Nebraska, New Jersey, New Mexico, Oregon, South Carolina, Utah and Virginia. 

What is the significance of Medicare Part A?

Most Medicare-eligible individuals are entitled to premium-free Part A coverage because of their work history or that of a spouse.  For those who are Medicare eligible but must pay for coverage themselves, the cost is very high: in 2008, the standard Medicare Part A monthly premium is $423, with a $1,024 deductible, and the Medicare Part B premium is $96.40, with a $135 deductible.  Because enrollment in Medicare Part A is a necessary prerequisite to receipt of MSP benefits, the high premium costs put some MSP programs (Specified Low-Income Beneficiary (SLMB) and Qualified Individual (QI)) out of reach for those without a sufficient work history to entitle them to zero-premium Part A coverage, such as senior immigrants who are U.S. citizens or have five years’ permanent residency. 

The QMB program, however, covers the Part A deductible, Part B deductible and premiums, co-insurance, and, in some cases, the Part A premium itself.  For low income individuals who qualify for Medicare yet do not have Part A, this is a crucial benefit. 

Enrollment in Part A and MSPs also affects access to prescription drug coverage.  As dual eligibles, MSP beneficiaries automatically qualify for the full Low-Income Subsidy for prescription drug coverage under Medicare Part D, and receive special rights and protections, such as facilitated enrollment into a Part D plan.  Conversely, failure to enroll in Medicare Part A during the general enrollment period could limit an individual’s access to prescription drug coverage.  Under the 2003 Medicare Modernization Act, states are not allowed to provide Medicaid prescription drug coverage to Medicare-eligible individuals for drugs covered under Medicare Part A (typically drugs provided during a hospital stay)—even if the individual is not actually enrolled in Part A.

How do individuals without Medicare Part A enroll in QMB?

To be eligible for QMB, an individual must be aged, blind, or disabled and have countable resources that do not exceed twice the maximum amount established for SSI eligibility and countable income that does not exceed 100 percent of the federal poverty guidelines.  42 C.F.R. § 400.200.  Countable resource limits are $4,000 for an individual and $6,000 for a couple, but may be higher in some states.  The current income eligibility limit for QMBs is $886.67 per month for an individual and $1186.67 per month for a couple, with higher limits in Alaska and Hawaii.  (This includes a universal $20 income disregard; additional disregards are allowed for earned income.) 

QMB applicants who do not already have Medicare Part A may apply “conditionally,” i.e., they may request Part A coverage conditioned on acceptance to the QMB program and subsidy of Part A premiums.  In order to sign up, eligible applicants should go to a local Social Security office and request “Conditional Medicare.”  See Social Security Administration, Program Operations Manual System (POMS) § HI 00801.140(D)(2), available online at https://s044a90.ssa.gov/apps10/poms.nsf/lnx/0600801140!opendocument.  For more information about conditional enrollment for QMB applicants, see the Center for Medicare Advocacy’s Fact Sheet, “Medicare Open Enrollment Ends March 31: Limited Opportunity to Expand QMB and LIS Coverage,”  http://www.medicareadvocacy.org/MedSavProgs_OpportunityForQMB.htm .