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Revision 09-4; Effective December 1, 2009
§359.101. Purpose and Scope.
(a) This chapter describes the assistance available and eligibility requirements for the Medicare Savings Program. Authorized under 42 U.S.C. §1396a(a)(10)(E), the Medicare Savings Program uses Medicaid funds to help eligible persons pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.
(b) The Texas Health and Human Services Commission (HHSC) manages the Medicare Savings Program, which consists of the following:
(1) the Qualified Medicare Beneficiary (QMB) Program;
(2) the Specified Low-Income Medicare Beneficiary (SLMB) Program;
(3) the Qualified Individual (QI) Program; and
(4) the Qualified Disabled and Working Individual (QDWI) Program.
(c) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.
§359.103. Qualified Medicare Beneficiary Program.
(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(i), the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles, and coinsurance for a person who meets the requirements of this section. A person receiving Medicaid may also receive QMB benefits if the person meets the requirements of this section.
(b) To be eligible for QMB coverage, a person must:
(1) be entitled to benefits under Medicare Part A; and
(2) meet income and resources requirements in 42 U.S.C. §1396d(p).
(c) A person is not eligible for QMB coverage if the person:
(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or
(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.
(d) A person's QMB eligibility begins on the first day of the month after the month the person is certified for QMB benefits.
(e) A person with QMB coverage is not eligible for three months prior medical coverage.
§359.105. Specified Low-Income Medicare Beneficiary Program.
(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iii), the Specified Low-Income Medicare Beneficiary (SLMB) Program pays only Medicare Part B premiums for a person who meets the requirements of this section. A person receiving Medicaid may also receive SLMB benefits if the person meets the requirements of this section.
(b) To be eligible for SLMB coverage, a person must meet the eligibility criteria for QMB coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have an income that is greater than 100% but less than 120% of the federal poverty level.
(c) A person is not eligible for SLMB coverage if the person:
(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or
(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.
(d) A person's SLMB eligibility may begin with the month of application.
(e) A person with SLMB coverage is eligible for three months prior medical coverage, if all criteria are met.
§359.107. Qualifying Individual Program.
(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iv) the Qualifying Individual (QI) Program pays only Medicare Part B premiums to a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QI coverage at the same time.
(b) To be eligible for QI coverage, a person must meet the eligibility criteria for Qualified Medicare Beneficiary coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have income that is at least 120% but less than 135% of the federal poverty level.
(c) Eligibility for QI coverage is determined for each calendar year.
(d) A person's QI eligibility may begin with the month of application.
(e) A person with QI coverage is eligible for three months prior medical coverage if all criteria are met. The three-month prior period cannot extend back into the previous calendar year.
§359.109. Qualified Disabled and Working Individual Program.
(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(ii), the Qualified Disabled and Working Individual (QDWI) Program pays only Medicare Part A premiums for a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QDWI coverage at the same time.
(b) To be eligible for QDWI coverage, a person must:
(1) be under 65 years of age;
(2) be entitled to benefits under Medicare Part A;
(3) not otherwise be eligible for Medicaid;
(4) have a monthly income equal to or less than 200% of the federal poverty level; and
(5) have no more than twice the countable resources allowed under the Supplemental Security Income (SSI) program, as described in §1611 of the Social Security Act (42 U.S.C. §1382).
(c) A person's QDWI eligibility begins in accordance with the coverage period described in §1818A of the Social Security Act (42 U.S.C. §1395i-2a(c)).