Medicaid Policy
Medicaid Policy
QI for Medicare Part B
QI pays the Medicare Part B-ID premium only.
Do not open QI:
If the member will be receiving ongoing Medicaid, which includes someone who is meeting a spenddown, cost of care contribution or MWI premium each month, OR
In the retroactive period if the member is receiving Medicaid without a spenddown, cost of care contribution or MWI premium for such months or is going to meet such applicable payments in the retroactive period.
Open QI:
If the member doesn't want to meet the spenddown, cost of care contribution or MWI premium, OR
If the member wants to meet a spenddown, cost of care contribution or MWI premium for only one or two months or every other month, OR
If the member stops receiving Medicaid because the spenddown, cost of care contribution or MWI premium has not been met for two months and the member meets all the QI criteria. Do not require a new application, OR
If a member asks that the Medicaid program be closed because the member does not want to meet the spenddown, cost of care contribution or MWI premium and the member meets all the QI criteria. Do not require a new application, OR
If eligible for QI under any of the above situations, include any of the months in which the member did not meet the spenddown, cost of care contribution or MWI premium and meets the QI eligibility criteria for each month.
Close QI:
If the member meets the spenddown, cost of care contribution or MWI premium and either wants to continue meeting it monthly or does continue to meet it for more than two months in a row; OR
If the member will be receiving ongoing Medicaid.
TPL process is not required (225)
QI is a permanent program; however, the funding is provided as an annual allocation for each state. When funds run low in a calendar year, the department will instruct DWS staff to deny any new applications. Open cases will be covered for the rest of that year.
If funding will not cover all QI members for the next calendar year, members open for QMB, SLMB or QI in the previous December receive priority enrollment in the new year. Priority is based on the date of the member’s most recent application for a cost-sharing program.
The benefit effective date for QI coverage is the first day of the application month or the first day of any of the three retroactive months in which the individual meets all the requirements for QI, given that funding is available. Always review eligibility for the retroactive months.
You can approve coverage for retroactive months in the previous year if funding was available for all QI members in the previous year.
If the agency had stopped allowing approval of QI cases because funding was insufficient in the previous year, January 1st of the current year is the earliest possible effective date for new applicants applying in the current calendar year
QI for Medicare PartB-ID
QI pays the Medicare Part B-ID premium only.
If a QI member is eligible for other Medicaid programs, Marketplace insurance, or employer insurance which cover immunosuppressant drugs, they are not eligible for the QI Part B-ID program.
TPL process is required (225)
The benefit effective date for QI coverage is the first day of the application month or the first day of any of the three retroactive months in which the individual meets all the requirements for QI, given that funding is available. Always review eligibility for the retroactive months.
You can approve coverage for retroactive months in the previous year if funding was available for all QI members in the previous year.
If the agency had stopped allowing approval of QI cases because funding was insufficient in the previous year, January 1st of the current year is the earliest possible effective date for new applicants applying in the current calendar year.