Action Request Transmittal Aging and People with Disabilities

Transcription

1 Action Request Transmittal Aging and People with Disabilities Mike McCormick Number: APD-AR Authorized signature Issue date: 2/11/2019 Topic: Medical Benefits Due date: Subject: Individuals Who May be Over Income for QMB/SMB/SMF and SMB/SMF/SBI/CBI Clients Who May Qualify for QMB/SMB as of March 1st Applies to (check all that apply): All DHS employees County Mental Health Directors Area Agencies on Aging: Type B Health Services Aging and People with Disabilities Office of Developmental Self Sufficiency Programs Disabilities Services (ODDS) County DD program managers Support Service Brokerage Directors ODDS Children s Intensive In Home Services ODDS Children s Residential Services Stabilization and Crisis Unit (SACU) Child Welfare Programs Other (please specify): Branch 5503 Action required: Generate and review ACCESS reports, change coding, and change or close/reduce benefits as appropriate. Reason for action: Medicare Savings Programs (MSP) recipients have protected eligibility from the start of the calendar year until the new income standards are instituted. The programs income standards are based on the Federal Poverty Level (FPL), which was published in January 2019 (see APD-PT ). The FPL increases by a set dollar amount rather than by a percentage. In prior years, this dollar amount either increased by an average lower percentage overall or a higher average percentage overall than the SSA COLA. In other words, the income standards for all household sizes were either higher or lower than the SSA COLA increase. This year, the results were mixed the one-person standards for QMB, SMB, and SMF increased by slightly more than 2.8% (the 2019 COLA increase), but the two or more-person standards increased by slightly less than 2.8%. This means that some SMB recipients currently in a one-person need group may qualify for QMB, and some SMF recipients subject to a one-person need group may qualify for SMB. It is also possible that some OSIPM cases coded with SBI or CBI

2 cases may now qualify for SMB (if subject to a one-person MSP need group). Alternately, some QMB, SMB, and SMF recipients subject to an MSP need group of two or more may be over income for their current MSP. The income standards are attached remember they take effect March 1, Individuals in one-person MSP need group who may qualify for QMB/SMB As a result of these changes, please take the following actions by 3/31/2019: All SMB cases must be reviewed for QMB eligibility and converted if appropriate All SMF cases must be reviewed for SMB eligibility and converted if appropriate SBI and CBI cases should be reviewed for SMB eligibility and converted if appropriate, do not convert SBI or CBI cases to SMF It is highly recommended that eligibility staff review P2 SMB cases first, since they have the most to gain by qualifying for QMB. OSIPM recipients will continue to have their Medicare deductibles, co-pays, and co-insurance covered by their OSIPM benefits; however, all MSP cases need to be reviewed as soon as possible. We are accountable to the federal government for the money we spend on Medicaid programs, so it is important that we enroll our clients in the program for which they are eligible, regardless of whether or not the changes are noticeable. Oregon ACCESS reports can be generated to assist with identifying cases for potential program changes, see below for instructions: To identify P2 SMB cases to review for QMB eligibility (do these first): Select P2 from the Program Code dropdown list Enter SMB in the C/D field (shown below) Leave Select all Living Situations checked Check the Select all Statuses box to ensure all cases are found To identify P2 SMF cases to review for SMB eligibility: Same as above except replace SMB with SMF

3 To identify all SMB/SMF cases to review for QMB/SMB eligibility: Leave the Program Code in its default value of * Enter SMB in the C/D field Leave Select all Living Situations checked Check the Select all Statuses box to ensure all cases are found Replace SMB with SMF to generate a report of SMF cases Note: This report will show P2 and OSIPM cases. To identify OSIPM cases with SBI or CBI for SMB eligibility: Enter SBI in the C/D field (shown below) Replace SBI with CBI to generate a report of CBI cases

4 There are also CA View reports that can assist with identifying some of these clients; however, they will not be available until later this month. Information about these reports will be provided in a subsequent transmittal. Individuals in two or more person MSP need group who may be over income for QMB/SMB/SMF as of March 1 The most critical are the P2 QMB-BAS recipients. Please work these first. If QMB- BAS only recipients are over income, their cases will go NA. Don t forget to screen individuals for potential MAGI eligibility before reducing. Please follow the procedures outlined in the APD MAGI Manual under the section titled: Due Process APD Medical Benefit Reduction No Services. Note: If you don t get to them it time and they go NA, artificially decrease the income so you can restore QMB effective 3/1/19. Wait one business day, correct the income, reduce effective 4/1/19, and send the appropriate notice (see below). The second category requiring immediate attention is P2 SMF-only since those cases must also be reviewed for MAGI by 5503 before being closed. Please follow the referral procedures outlined in the APD MAGI Manual under the section titled: Due Process Closure of MSP-Only Case. Individuals moving from SMB-only to SMF-only do not require a notice or a MAGI review as their benefits will not change. Full dual-eligible individuals (OSIPM with MSP) either changing from QMB-BAS to SMB, or SMB to SBI/CBI require a notice but no MAGI review. Please see APD Worker Guide G.9 for decision notice instructions: Remember that full dual-eligible individuals who are over-income for SMB cannot be moved to SMF. Until the CA View reports are not yet available, Oregon ACCESS reports can be generated to assist with identifying cases for potential program changes, see below for instructions: To identify P2 QMB cases for reduction to SMB (do these first): Select P2 from the Program Code dropdown list Enter QMB in the C/D field (shown below) Leave Select all Living Situations checked Check the Select all Statuses box to ensure all cases are found To identify P2 SMF cases to review for closure (do these second): Same as above except replace QMB with SMF

5 To identify P2 SMB cases to review for SMF eligibility (do these last): Same as above except replace SMF with SMB Field/stakeholder review: Yes No If yes, reviewed by: APD Operations, APD Policy If you have any questions about this action request, contact: Contact(s): Phone: Fax:

6 Medicare Savings Program Income Standards as of March 1, 2019 QMB-BAS Family Size Income Standard 1 1, , , , , , , , , ,356 Each Addl Person 369 QMB-SMB Family Size Income Standard 1 1, , , , , , , , , ,227 Each Addl Person 442 QMB-SMF Family Size Income Standard 1 1, , , , , , , , , ,881 Each Addl Person 498