PM 06-14-03

  1. (CO) Verifies Medicare Part A and Part B enrollment through BENDEX.
  2. (CO) Generates monthly list, called "Potential QI-1 Eligible Cases", of cases with Item 90 income of more than $25 plus QI-1 income limit for a single person. List shows cases which Family Community Resource Center must review.

    Cases are listed: 

    • for Category 91, 92, and 93 cases, when Code HIB status indicator 4 is centrally added in Item 60, no SMIB status indicator appears, and a Code HIB status indicator did not previously appear; and
    • when Code 390 SPD appears in Item 80.

      The list shows the: 

    • case name,
    • case ID number,
    • RIN, and
    • total income amounts from Item 90.
  3. (FCRC) Use Form 2382M to decide if monthly countable income is within QI-1 income limit.

    NOTE: Spenddown clients are QI-1 eligible if they have income above SLIB income limit, but at or below QI-1 limit. Spenddown enrollment shows that other QI-1 eligibility requirements are met. 

  4. (FCRC) Complete Form 552 when the applicant is QI-1 eligible:
    Item 3 -TA 31
    Item 33 -TAR 41
    Item 60 -Social Security/Medicare Claim Number or Railroad Retirement Claim Number. Enter MM/YY of QI-1 eligibility and status indicator 3 following code QMB. QI-1 eligibility may be effective 3 months before application.
  5. (FCRC) Send QI-1 eligible applicant or caretaker the Notice Regarding Medicaid Payment of Medicare Part B Premiums (Form 3420).

    NOTE: Send Form 3420 to each client converted to QI-1 status by the Family Community Resource Center, whether or not they appear on "Potential QI-1 Eligible Cases" list.