A. Benefits for MCSP and Part B-ID MCSP
QI pays the Medicare Part B and Part B-ID premium only.
B. TPL
TPL process is only required for Medicare Part B-ID MCSP.
C. QI and Other Medicaid Programs for MCSP
1. Do not open QI:
a. 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
b. 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.
2. Open QI:
a. If the member doesn't want to meet the spenddown, cost of care contribution or MWI premium;
b. If the member wants to meet spenddown, cost of care contribution or MWI premium for only one or two months or every other month;
c. If a 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
d. 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.
e. 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 such months.
3. Close QI:
a. 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
b. If the member will be receiving ongoing Medicaid.
D. QI and Other Medicaid Programs for Medicare Part B-ID MCSP
QI-1 members who are eligible for other Medicaid programs, Marketplace insurance, employer insurance, etc. which cover immunosuppressant drugs are not eligible for the Medicare Part B-ID MCSP programs.
E. Limited Funds for MCSP not including Medicare Part B-ID MCSP
1. 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. We will cover open cases for the rest of that year.
2. 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.
F. Benefit Effective Date for MCSP
1. 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.
2. You can approve coverage for retroactive months in the previous year if funding was available for all QI members in the previous year.
3. 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.
G. Benefit Effective Date for MCSP
The effective date for QI-1 coverage is the first of the month of the application month. There is no retroactive coverage.