2145 Qualifying Individuals – 1 | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Qualifying Individuals – 1

Effective Date:

February 2020

Chapter:

2100

Policy Number:

2145

Previous Policy Number(s):

MT 51

Updated or Reviewed in MT:

MT-58

Requirements

Qualifying Individuals – 1 (QI-1) is a Q Track class of assistance (COA) that pays the monthly premium for Medicare supplemental Medical Insurance (Part B) for individuals who meet financial criteria based on a percentage of the Federal Poverty Level (FPL). Eligibility criteria are identical to SLMB except that the coverage is time limited depending on available State funds and the income limit is higher than the SLMB limit.

Basic Considerations

To be eligible under this COA, an A/R must meet the following conditions:

The A/R is entitled to Part A Medicare coverage.

The A/R meets all basic eligibility criteria.

Since QI-1 recipients receive Medicare, they are exempt from the citizenship verification requirement. Citizenship was verified by SSA prior to awarding Medicare. The Declaration of Citizenship form is still required.

Application for Other Benefits, Third Party assignment, Length of Stay (LOS) and Level of Care (LOC) are not requirements under this COA.

The A/R has countable resources of less than or equal to the current QMB/SLMB/QI-1 resource limit.
The A/R has countable net income of less than the QI-1 income limit but greater than the SLMB income limit.

QI-1 pays only the monthly premium for Part B Medicare for the QI1 eligible individual.

Retroactive coverage (three months prior and intervening months) is allowed under this COA. QI-1 eligibility cannot pre-date January 1998.

The QI-1 income limit is based on the federal Poverty level (FPL). The FPL/QI-1 income limit is subject to change between February and April of each year. Therefore, the annual January RSDI COLAs are disregarded in determining QI-1 eligibility until the effective month of the new QI-1 income limit.

In-kind support and maintenance (ISM) is NOT considered in determining QI-1 eligibility.

THE STANDARD OF PROMPTNESS FOR PROCESSING A SLMB APPLICATION IS 10 WORKING DAYS FROM THE DATE OF RECEIPT OF THE APPLICATION.

Special Considerations

The 1999 Government Performance Results Act simplified the policy and procedures for this class of assistance and has changed the application process. In addition to applying at the county office, an A/R may apply with the local Community Health Center or with HICARE on a simplified application form, DCH 700, Medicare Savings for Individuals. (County DFCS shall also use Form 700 for initial applications and annual reviews. It is available from Central Supply.)

The local Community Health Center and HICARE will forward all applications to DMA, who will forward the applications to the appropriate County Departments. The application date is the date stamped as received by DMA.

Procedures

Follow the steps below to determine QI-1 eligibility.

Step 1

Accept the A/R’s QI-1 application. Since this is a time limited program, it is important to take and process applications in chronological order.

Step 2

Contact the A/R by telephone only if information provided on the application is not sufficient to process the case.

A face-to-face contact and office interview is not required at initial application or annual redetermination.

Step 3

Verify Part A Medicare entitlement by one of the following:

client statement, if copy of card or other written verification is not provided or available
a RSDI Award Letter
a Medicare card
BENDEX under Clearinghouse on the system
an MBR Query Card
notification from a local SSA office

If the A/R has not been approved for Part A Medicare, but is entitled to free Part A obtain notification from SSA, scan into document imaging system and process QI-1 as though the A/R is currently covered by Part A Medicare. (If an A/R is required to pay a premium to receive Part A Medicare, they are not considered entitled for purposes of eligibility for QI-1.)

Step 4

Determine all basic eligibility criteria except LOS, LOC and Application for Other Benefits. Accept the A/R’s statement regarding residency. Refer to Chapter 2200, Basic Eligibility Criteria.

To fulfill the TPR requirement on a QI-1 applicant who has a TPR, copy the application and send to DMA only if the QI-1 applicant becomes Medicaid eligible under another COA.

Step 5

Determine financial eligibility using QI-1 income and resource limits. Refer to the 2500 ABD Financial Responsibility and Budgeting Overview to determine the following:

whose income and resources to consider
which QI-1 income and resource limit (individual or couple) to use
which eligibility budget to complete

Effective July 1, 2016, the DCH adopted SSA’s Low Income Subsidy definition for “family of the size involved” for the QI1 Class of Assistance only. This means we will use the couple income and resource limit for the individual and the individual’s spouse, whether or not the spouse is applying (Medicare Eligible) for the QI1 MSP. We will continue to follow the approach of the SSI program under which either the standard for an individual or the standard for a couple will be used for the QMB and SLMB Medicare Savings Programs.

For all applications and annual redeterminations: The A/R’s statement of income and resources provided on the application/review form is acceptable verification. No further verification is required unless questionable. If BENDEX/SDX or other information known to the agency indicates a different amount from the A/R’s statement and is determined to be current, use this amount over the A/R’s statement.

If a Medicare eligible couple both apply for a Q Track COA and they are income ineligible as a couple for all Q Track COA, calculate their eligibility as individuals for income but jointly for resources and approve each under whichever Q Track COA they are eligible.

No property search is required for this class of assistance.

The Social Security number of a spouse who is not applying for benefits is not required unless eligibility cannot be established without it.

Except for AMN, an individual cannot be dually eligible for QI-1 and another Medicaid COA for ongoing eligibility. If an active QI-1 A/R applies for and is approved ongoing under another COA, close the QI-1 case.

Step 6

Approve QI-1 on the system if the A/R meets all the above eligibility Requirements.

Step 7

Notify the A/R of the case disposition via the system generated notice.