WAG 06-12-02-b: Dual Eligibility (QMB/Medicaid)

PM 06-12-02-b

1. (FCRC) Decide QMB eligibility for all cash and/or medical applicants who are Part A beneficiaries.
   1. Give applicant Medicaid Payment of Medicare Cost Sharing Expenses (Form 3120).
2. (FCRC) Verify Part A enrollment.

   NOTE: Application for Payment of Medicare Premiums, Deductibles and Coinsurance (Form 2378M) is not needed. 

   1. Send applicant Instructions to Client (Form 267) to request proof of Part A coverage (such as Medicare card or SSA award letter), if Medicare Part A eligibility was claimed by applicant but not verified.
   2. Help client, if needed, get verification of Part A enrollment or any other required information.

      NOTE: Initiate an SOLQ inquiry if client asks for help getting verification of Part A. 

3. (FCRC) Determine countable monthly income and nonexempt assets to apply to the QMB income and asset limits using Form 2382M.
4. (FCRC) Decide QMB eligibility within 45 days from application date. For a Category 93 application, QMB eligibility must be decided within 45 days and Medical eligibility within 60 days.
5. (FCRC) For Cash and Medical cases, if applicant is enrolled for Medicare Part A and Medicare Claim Number or Railroad Retirement Claim Number is entered in Item 60, use AIS to enter QMB status indicator in Item 60.

   NOTE: If application decision is made on last workday of month and AIS is down, approve application through IPACS. 

6. (FCRC) If a case is approved with a Railroad Retirement Board claim number, use Discrepancy Referral (Form 1925) to send the RRB claim number to SSA/PCU.

Application processed through IPACS

1. (FCRC)  For AABD Cash applications, decide QMB eligibility as well as eligibility for cash.
   1. Complete Form 552 (see WAG 25-08-02-a).
   2. Enter client's Medicare Claim Number or Railroad Retirement Claim Number in Item 60.
   3. Also enter the following in Item 60:
      • code HIB followed by status indicator 3;
      • code SMIB followed by status indicator 5, if person is also enrolled in Medicare Part B; and
      • QMB and status indicator 1.
2. (FCRC) For TANF applications, decide QMB eligibility as well as eligibility for cash or medical.
   1. Complete Form 552 if aid is approved and a family member is QMB eligible.
3. (System) Enters month/year of beginning QMB eligibility in Item 60 following code QMB.
   1. (FCRC) Enter month/year of beginning QMB eligibility in Item 60, only if application decision is made on last workday of month and IPACS is down. For example, application is approved on 09/30/97. IPACS is down and approval action cannot be taken until 10/01/97. Since eligibility was decided in September, effective date of QMB eligibility is 10/01/97. Enter 101997 after code QMB.
4. (FCRC) Send the Notice Regarding Medicare Cost Sharing (Form 3132), when QMB benefits are approved on an active case.
5. (FCRC) Send approval notice about cash and/or medical.

Application for cash/medical pends for more than 45 days

1. (FCRC) Approve application for QMB Only benefits, if QMB eligible (see WAG 17-02-04).
   1. Use TAR 95 to cancel QMB Only case. This allows a 3-month extension of QMB, starting with the effective month of the cancellation action, to decide eligibility for other benefits.
   2. Do not put an entry in Item 77.
   3. Do not send a cancellation notice.
   4. Registers application using same case ID number and date of application.
   5. Approve QMB benefits when Cash or Medical is approved.
2. (FCRC) If QMB eligibility does not exist, deny the QMB request no later than the 45th day. Send a Notice of Decision on Application for Medicare Premiums, Deductibles and Coinsurance (Form 458M).
   1. Show that a decision has not been made on the Cash and/or Medical application.
3. (FCRC) Deny the Cash or Medical application if the applicant is not eligible for Cash or Medical.
   1. If the applicant may be QMB eligible, decide if they qualify for QMB.

      NOTE: Determine QMB eligibility if the Cash or Medical denial was based on the applicant's failure or refusal to cooperate with a request, when the request is not necessary to decide QMB eligibility; such as failure to appear at an interview. 

   2. If eligible for QMB, follow procedures for approving QMB Only benefits (see WAG 06-12-02-a).
   3. Reregister the application for QMB Only benefits, on the same day as the denial. Use the original date of application and reregister through AIS. If the original application was registered as Category 01, 02, 03, 91, 92, or 93, use the same basic number.
4. (FCRC) If applicant is not eligible for Cash, Medical, or QMB, send the denial notice for the Cash or Medical application. Do not reregister the application for QMB Only.