Individuals Covered and Benefits 510-05-60-10

(Revised 8/1/2023 ML #3745)

 

(N.D.A.C. Sections 75-02-02.1-22(1) and 75-02-02.1-10)

 

SSI Buy-in

• This coverage is for individuals who have SSI income and Medicare Part B only.

 

Medicare Savings Program (MSP)

 

1. Qualified Medicare Beneficiaries (QMB)- Eligible individuals must have Medicare Part A and meet the following conditions: 

• Are entitled to payment of Medicare Part B, and/or

• Payment of premium Part A for individuals who:

1. Are over 65 eligible for SSI income (with no Medicare Part A); or

2. Lose SSI income and are no longer eligible for SSI buy-in; or

3. Have requested North Dakota Medicaid to pay the Medicare Part A premium; or

4. Have Medicare Part A coverage because another state was paying the premium for Part A and the individual is now a resident of North Dakota; or

5. Are over 65 not eligible for SSI buy-in (no SSI income), do not have free Medicare Part A or have any means to pay (no income or very low income) for Medicare Part A or Part B premiums.

   1. Will need to apply for "Conditional Medicare Part A" through Social Security if they have not already done so.

• Are entitled to Medicare cost sharing benefits beginning the month following the month the individual is determined eligible.

• Example 1- Application received March 29th. Eligibility processed in the system on May 1st. Individual is determined eligible for the month of March with QMB coverage starting April 1st ( the month after the month the individual is determined eligible).

• Example 2- Application received February 15th. Individual is requesting three prior months. The application is processed March 1st. The individual is eligible for QMB in February, with QMB coverage starting March 1st ( the month after the month the individual is determined eligible). The individual is within the income level for QMB in the three prior months however, eligibility for QMB cannot be established for the three prior months.

• Individuals ongoing eligible for Medicaid, who become eligible for Medicare, QMB can start the month Medicare starts if the individual is eligible for QMB in the month prior to the month Medicare starts.

 

2. Specified Low-Income Medicare Beneficiaries (SLMB) - Eligible individuals must have Medicare Part A and meet the following conditions:

• Are entitled only to the payment of their Medicare Part B premium

• Eligibility may be established for as many as three calendar months prior to the month in which the application was received or the date SSA received the Low-income Subsidy application.

• If the individual only has Medicare Part A, Part B can be added with a coverage start date of when ND can pay the Part B premium.

 

3. Qualifying Individuals (QI)- Eligible individuals must have Medicare Part A and meet the following conditions

• Are entitled to only payment of their Medicare Part B premium

• Eligibility may be established for as many as three calendar months prior to the month in which the application was received or the date that SSA received the Low-income Subsidy application.

• Cannot be in receipt of any other Medicaid coverages for the same time period

• A QI individual can request coverage for the other Medicaid benefits, and eligibility can be established, only if the QI individual repays the Medicare premium(s) payment received for the month(s) the other Medicaid benefits are needed. Medicaid benefits can only be authorized after the Medicare premium(s) payment have been repaid.

• When a recipient needs to reply Medicare premiums, a check or money order can be made payable to the "Dept of Health & Human Services" and collected by the Zone. The Zone office must forward the check or money order to the Finance Division of the ND Dept of Health and Human Services with a completed Medicaid credit form, SFN 828. A copy of the form can be found at 05-100-05

 

Note: Each year the federal government allocates a set amount of funds that can be used to provide coverage for QI individuals. In the event the allocation for North Dakota is exhausted in any given year, current recipients remain eligible, but additional person(s) cannot be added.

 

4. Qualified Disabled Working Individuals (QDWI)- Eligible individuals must meet the following conditions:

• Are entitled to payment of Medicare Part A premium only.

• Individuals who are:

  • Under 65 years old,

  • Working,

  • Lost their premium-free Medicare Part A due to returning to work

  • Are receiving medical assistance and meet the income and resource limits.

• Coverage for QDWI began July 1, 1990

   

Note: SPACES is not set up to accommodate this coverage in the system. Any inquiries for this coverage, send request to DHHS Medicaid Policy hccpolicy@nd.gov with QDWI in the subject line.

 

5. Part B-ID- Eligible individuals must meet the following conditions:

• Are entitled to coverage for Medicare Part B-ID premium only.

• Have been in receipt of Medicare coverage under Medicare End Stage Renal Disease (ESRD) entitlement which is ending 36 months after a successful transplant

• Cannot have any other coverage under Medicaid

• Coverage for this group began January 1, 2023

Note: Social Security determines if an individual is eligible for Medicare Part B-ID

 

Note: SPACES is not set up to accommodate this coverage in the system. Any inquiries for this coverage, sent requests to DHHS Medicaid Policy unit at hccpolicy@nd.gov with Part B-ID in the subject line.