IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 1: SPECIAL MA GROUPS AND PROGRAMS
QUALIFIED INDIVIDUALS (QI-1) 1.13
AR: N/A
AX: N/A
SR: N/A
QM: A QI-1 is a Medicare beneficiary whose income is at least 120 percent of the FPL and less than 135 percent of the FPL and whose resources are no more than twice the SSI standard. The Medicaid program pays the Medicare Part B premium for a QI-1. (Note that effective July 1, 2005, there are no QI-1 eligible customers, since the QM and SLMB income limits have been increased to include these customers.)
QI-1 coverage begins the month of application. Additionally, QI-1s are eligible for the three-month retroactive eligibility determination.
There are no spend-down provisions for QI-1s.
QUALIFIED DISABLED AND WORKING INDIVIDUALS (QDWI) 1.14
AR: N/A
AX: N/A
SR: N/A
QM: A QDWI is an individual who:
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lost his/her free Medicare Part A benefits due to his/her return to work,
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is eligible to receive or receives Medicare Part A,
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has income that does not exceed 200 percent of the FPL,
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has assets that do not exceed twice the SSI limit, and
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is not eligible for MA under any other category.
Benefits for QDWIs are limited to payment of Medicare Part A premiums only.
Use the SR methodologies to determine income and resource eligibility.
Eligibility as a QDWI is effective on the date all eligibility factors are met. Three-month retroactive eligibility is available to QDWIs. There are no spend-down provisions for QDWI eligibility.
If a customer appears to be eligible as a QDWI, please contact the Policy Unit for assistance in processing the case.
| Ms. Lindsay applies for benefits on October 1 and is enrolled in Medicare Part A. Her eligibility is effective October 1 (or up to 3 months retroactively if all eligibility criteria are met). |
DISABLED INDIVIDUALS RETURNING TO WORK 1.15
AR: N/A
AX: N/A
SR: Certain SSI recipients and former recipients are eligible for continued SR coverage even if their earnings appear to make them over-income. These customers may be covered under 1619(a), 1619(b), Plans to Achieve Self-Sufficiency (PASS), and other relevant provisions of the Social Security Act. If a customer formerly received SSI, even in the distant past, and now appear over-income for SR due to earnings, please contact the Policy Unit for guidance.
QM: See SR above. Former SSI beneficiaries may actually be eligible for continued SR coverage if they lost SSI because of increased earnings. These new or recertifying customers often appear to be (a) ineligible for SR but (b) eligible for QM due to the increase in earnings. In addition, this group includes customers who may have stopped receiving SSI in the past and may until now have appeared to be SR eligible. Please contact the Policy Unit for guidance.
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Mr. Gomez applies for SR Medicaid but appears to be over-income due to earnings. The SSR notes that Mr. Gomez received SSI between 1992 and 1999 and promptly contacts the Policy Unit for guidance. With assistance from the Policy Unit, the SSR directs Mr. Gomez to complete several forms; after doing so, Mr. Gomez becomes automatically entitled to Medicaid coverage.
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| Ms. Jackson recertifies for SR Medicaid but appears to be over-income because of earnings. The SSR notes that Ms. Jackson received SSI until recently; her SSI termination actually generated the recertification notice. The SSR contacts the Policy Unit for guidance; with assistance from the Policy Unit staff, the SSR directs Mr. Gomez to complete several forms; after doing so, Mr. Gomez becomes automatically entitled to Medicaid coverage. |
AR: N/A
AX: N/A
SR: N/A
QM: N/A
MC: This special Demonstration program provides Medicaid benefits to customers age 50-64. These customers must have income and resources below the Medically Needy income limits, and they must meet all other criteria for Medicaid (e.g., citizenship/alienage, SSN, District residency, etc.) except disability.
However, application for the 50-64 Demonstration was suspended on November 5, 2003. These customers are enrolled in the MC program type in ACEDS and use the 370 program code.
Note: The MC program type in ACEDS is also used by the DC HealthCare Alliance Program, which uses the 470 and 460 program codes; please see Chapter 4: DC HealthCare Alliance Program in this Part for additional information.
