Section 8

Public Benefit Programs

I. Public Benefits Programs ............................................................................................. 2

II. Income and Resources ................................................................................................. 2

A. Income ............................................................................................................... 2

B. Resources ........................................................................................................... 2

III. Supplemental Security Income (SSI) ......................................................................... 2

A. Description ......................................................................................................... 2

B. Eligibility Criteria .............................................................................................. 3

IV. MO HealthNet (Medicaid) ......................................................................................... 3

A. Description ......................................................................................................... 3

B. Eligibility Criteria .............................................................................................. 3

V. MO HealthNet Spend-Down (Medicaid Spend-Down) ............................................... 4

A. Description ......................................................................................................... 4

VI. Home and Community Based Services (HCB) ........................................................... 6

A. Description ......................................................................................................... 6

B. Eligibility Criteria .............................................................................................. 6

VII. Medicare Saving Programs ....................................................................................... 6

A. Qualified Medicare Beneficiary (QMB) Program ............................................... 6

B. Specified Low-Income Medicare Beneficiary (SLMB) Program ........................ 7

C. Qualifying Individual–1 (QI-1 and/or SLMB Group 2) ...................................... 8

D. Low Income Subsidy (LIS or “Extra Help”) ....................................................... 8

E. Missouri Rx (MORX) - Missouri’s State Pharmacy Assistance Program

(SPAP) ..................................................................................................................... 10

VIII. Section 8 Review .................................................................................................. 11

The Following documents are located at the end of this section:

MSP Application

Why spend down brochure

LIS Detailed Table

CMS Guide to Consumer Mailings

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I. Public Benefits Programs

In Missouri, the Family Support Division (FSD) provides financial assistance and health

insurance coverage to those eligible. The division offers many different programs for

families, the disabled, and the elderly. In this manual, we specifically address those programs

most relevant to Medicare beneficiaries: MO HealthNet (Medicaid), MO HealthNet Spend-

Down, Home and Community Based Services, and the Medicare Savings Programs - QMB,

SLMB, and QI-1. Medicare beneficiaries who are eligible for any form of MO HealthNet

benefits are known as dual-eligible. In addition, we address the Social Security

Administration’s (SSA) SSI program.

II. Income and Resources

A. Income

1. Types of income

a. Earned income (e.g. wages)

b. Unearned income (e.g. Social Security, pension (whether it is reportable to the

IRS or not), bank interest)

2. Allowed exclusion - $20 general exclusion is applied against income (per individual

or couple and is included in the money tips sheet income guidelines)

B. Resources

1. Countable resources - savings accounts, retirement accounts, checking accounts, non-

home real estate

2. Resource exclusions

a. The homestead - The homestead, including adjoining land, is excluded as long as

the individual; spouse; or minor, disabled, or blind child is living in it. If the

person goes from their home to a nursing home, then the home is also exempt.

b. Life insurance - The cash value of a life insurance policy is excluded up to

$1,500.

c. Automobile - The value of one automobile is excluded. Under Medicaid, an

additional automobile may be excluded, if the need for the vehicle can be proven.

d. Irrevocable Burial Trust (Fund/Account)

e. Burial Space - Plots, crypts, or mausoleums of any value are excluded.

III. Supplemental Security Income (SSI)

A. Description

SSI is a federally funded income assistance program for those 65 or older, the blind, and the

disabled. The purpose of the program is to ensure a minimum level of income for people

who do not have enough income or resources to maintain a minimum standard of living. SSI

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“supplements” the individual’s income to bring them up to a set income level. Enrollment

for SSI is done through the Social Security Administration. Beneficiaries who qualify for

this level of public benefits automatically qualify for “extra help” in paying for Medicare

Prescription Drug coverage and in most cases will also qualify for full Mo Health Net

benefits.

B. Eligibility Criteria

1. Must be over 65, blind, or disabled

2. Must be a US citizen or permanent resident of the US

3. Must have limited income

4. Must have limited resources

IV. MO HealthNet (Medicaid)

A. Description

MO HealthNet (Medicaid) is a public assistance program that pays for certain health care

costs. For Medicare beneficiaries, MO HealthNet supplements Medicare benefits. MO

HealthNet (Medicaid) is always the payer of last resort. Enrollment for MO HealthNet is

done through the Missouri Family Support Division (FSD).

If eligible for Medicare, individuals who qualify for this level of public benefits

automatically qualify for “extra help” in paying for Medicare Prescription Drug coverage.

These individuals will pay the lowest co-pays offered. When becoming eligible for

Medicare, if they do not enroll in Medicare Prescription Drug plan or Medicare

Advantage with drug coverage, they will automatically be enrolled in a plan. This level of

“extra help” also allows the ability to change plans once every quarter for the first three

quarters of the year if necessary.

B. Eligibility Criteria

1. Must be a U.S. citizen or permanent resident of the U.S.

2. Must have income below 85% of the federal poverty level for

the assistance group size (household size)

3. See Money Tip Sheet for current resource limits.

See Money

Tip Sheet!

See Money

Tip Sheet!

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V. MO HealthNet Spend-Down (Medicaid Spend-Down)

A. Description

MO HealthNet Spend-Down is a public assistance program that pays for certain health

care costs of qualified persons. This program is for those with income above the MO

HealthNet limits. It allows them to “spend down” or “pay down” their income to the

Medicaid limit in order to receive benefits. The spend-down amount is determined on a

monthly basis. In order for MO HealthNet to pay for medical expenses a person must

meet or exceed their spend-down amount for that month. A person is not required to pay

or meet that amount every month for general purposes of maintaining MO HealthNet.

Enrollment for MO HealthNet Spend-Down is done through FSD.

B. Eligibility Criteria

To determine the spend-down amount, the FSD Eligibility Specialist first determines the

total monthly gross income based on the following:

Earned income (e.g. wages)

Unearned income (e.g. Social Security, pension, bank interest)

Then the FSD Eligibility Specialist subtracts the following:

$20 personal income exemption (included in amounts listed in the Money Tip

Sheet)

Amount paid each month for Medicare and certain types of medical insurance

(Medigap policy, EGHP premium)

85% of the current federal poverty level (MO HealthNet ceiling) for 2019 which is

$905/mo (single) and $1,218/mo (couple)

The remainder is the spend-down amount.

MO HealthNet Spend-Down Example

Monthly Income $1,200.00

Recurring Expenses

Personal Exemption Amount -$20.00 $1,180.00

Medicare Premium -$104.90 $1,075.10

Medigap Premium -$105.00 $970.10

Recurring Expenses Subtotal -$229.90 $970.10

Medicaid Income Limit -$905.00 $65.10

Monthly Spend-Down Amount $65.10

Potential Drug Spending -$30.00 $35.10

Other Potential Medical expenses

(Part B deductible) -$185.00 -$149.90

Total $1,347.80

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To meet a spend-down, gather the following receipts or bills for the month to give to the

FSD Eligibility Specialist: prescription drugs, hospitalization, and doctor care, and other

medical services. You may use: Bills that are currently owed to meet Spend Down in a

different month than when they were incurred.- Eligible expenses incurred in the three

months prior to the current month. If the amount of expenses from prior months exceeds

the current month’s Spend Down amount, the excess balance can be used towards Spend

Down for the following three months.

Another option is to pay the spend-down amount directly to the state. A paid-in spend-

down amount will be refunded after 13 months if there were no medical claims for that

month.

On the day medical expenses equal the spend-down amount, the FSD Eligibility Specialist

will activate medical benefits. MO HealthNet benefits will be available to pay for covered

services above the spend-down amount. Coverage will end on the last day of the month

spend-down was met or exceeded.

If eligible for Medicare, individuals that qualify for Medicaid, automatically qualify for

“Extra Help” in paying for Medicare Prescription Drug coverage. If your spend-down is

met at least once January to July, your Extra Help will continue for the rest of the

calendar year. If met after July through December, it will continue through the entire

following calendar year.

When becoming eligible for Medicare, if they do not enroll in a Medicare prescription

drug plan or Medicare Advantage with drug coverage, they will automatically be enrolled

in a plan. This level of “Extra Help” also allows the ability to change plans every quarter

for the first three quarters if necessary. If a beneficiary does not meet their spend-down,

causing them to lose their Medicaid status, he or she will need to complete the Social

Security extra-help application to ensure continued assistance in paying for their

prescription drugs if they qualify or meet their spend down amount again.

Example: If met in February 2019, Extra Help will continue through December 2019. If met

in November 2019, Extra Help will continue through December 2020. These individuals

will pay the same co-pays as someone on a Medicare Saving Program.

Counseling Note: There is a spend-down unit with a phone number with representatives who can

answer any question regarding spend-down for counselors or beneficiaries at 1-855-600-4412.

You may also go to https://dss.mo.gov and search for “spend down” for further detailed

information.

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VI. Home and Community Based Services (HCB)

A. Description

This program is for individuals 63 years and older, who are unable to live in their homes

independently, without services of homemaker chores or respite care. These individuals must

meet nursing home criteria based on an assessment of needs for care, by Missouri Health and

Senior Services. Once the assessment determines services are needed in the home to delay or

prevent placement in a nursing home, the Family Support Division is contacted to determine

eligibility to receive coverage under MO HealthNet. Once approved, Health and Senior Services

will develop and administer home and community delivery services to meet the unmet needs.

Some services that can be provided may include personal care, homemaker chores, nursing,

respite, adult day care, and counseling. The beneficiary does have the option to direct these

services under consumer-directed care. A family member or friend could be hired by the

beneficiary to fulfill the services approved under the care plan by Health and Senior Services.

B. Eligibility Criteria

1. 63 years or older

2. Monthly income $1,311.00 (Jan. 1, 2019) or lower and assets under $3,000

3. Meets nursing home level of care according to the Needs of Care Assessment completed by

Missouri Health and Senior Services

4. Authorization of services given by Missouri Health and Senior Services

5. Meets the requirements of eligibility of MO HealthNet

VII. Medicare Saving Programs Medicare Savings Programs (MSP) are a federally and state funded programs administered

by each individual state. These programs are for people with limited income and resources

and help pay some or all of their Medicare premiums, deductibles, copayments and

coinsurance.

A. Qualified Medicare Beneficiary (QMB) Program

1. Description

The QMB program is a federal and state funded assistance program that assists

certain low-income Medicare beneficiaries by paying their Medicare premiums Part

A and B, deductibles, and coinsurance. Enrollment in QMB is done through Missouri

Family Support Division (FSD).

This MO HealthNet program is the only program that will pay for Medicare

Advantage Plan cost sharing (deductibles, coinsurance, and copayment) for

participants in QMB and QMB Plus. QMB Plus participants have resources at the

MO HealthNet level.

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2. Eligibility criteria

Income must not exceed 100% of the federal poverty level for

the assistance group size (household size)

a. See “Money Tip Sheet” for current resource limits

b. The effective date of QMB benefits is the month following

the month of approval by Family Support Division.

Individuals that qualify for QMB automatically qualify for “extra help” in paying for

Medicare Prescription Drug coverage. These individuals will pay the medium level of

co-pays. When becoming eligible for Medicare, if they do not enroll in Medicare

prescription drug plan or Medicare Advantage with drug coverage, they will

automatically be enrolled in a Part D plan. This level of “extra help” also allows the

ability to change plans every quarter for the first three quarters (January-March,

April-June, or July-September) if necessary.

B. Specified Low-Income Medicare Beneficiary (SLMB) Program

1. Description

The SLMB program is a federal and state funded assistance program that assists

certain low-income Medicare beneficiaries by paying their Medicare Part B

premiums. Enrollment in SLMB is done through the Missouri

Family Support Division (FSD).

2. Eligibility criteria

a. Must have limited incomes between 100% of the federal

poverty level and 120% of the federal poverty level for the assistance group

size (household size)

b. See “Money Tip Sheet” for current resource limits

c. The effective date of SLMB benefits is the month of application to Family

Support Division and prior quarter may be considered.

Individuals that qualify for SLMB automatically qualify for “extra help” in paying for

Medicare Prescription Drug coverage. These individuals will pay the medium level co-pays.

When becoming eligible for Medicare, if they do not enroll in a Medicare prescription drug

plan or Medicare Advantage with drug coverage, they will be automatically enrolled in a

Part D Plan. This level of “extra help” also allows the ability to change plans every quarter

for the first three quarters (January-March, April-June, or July-September) if necessary.

See Money

Tip Sheet!

See Money

Tip Sheet!

Counseling Note: Even if beneficiaries have been automatically assigned a Part D plan, the counselor

should run a personal comparison of their drug plan options. This will make sure the plan they have

been assigned will cover their medications and to see if another plan may be less expensive. There

could also be a delay of up to two months before an assigned plan will take effect. By doing an

enrollment, the waiting period will be eliminated. If there is a waiting period, a Limited Income

Newly Eligible Transition Program (LINet) is available to assist with prescription coverage during this

time. Please refer to section D6 for further details.

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C. Qualifying Individual–1 (QI-1 and/or SLMB Group 2)

1. Description

The QI-1 program is a federally funded assistance program that assists certain low-

income Medicare beneficiaries by paying their Medicare Part B premiums.

Enrollment in QI-1 is done through the Missouri Family Support Division (FSD).

2. Eligibility criteria

a. Must have a limited income that does not exceed

135% of the federal poverty level of the assistance

group size (household size)

b. See “Money Tip Sheet” for current resource limits

c. The effective date of QI-1 benefits is the month of

application to Family Support Division and prior quarter may be considered.

Individuals that qualify for QI-1 automatically qualify for “extra help” in paying for

Medicare Prescription Drug coverage. These individuals will pay the medium level

co-pays. When becoming eligible for Medicare, if they do not enroll in Medicare

prescription drug plan or Medicare Advantage with drug coverage, they will

automatically be enrolled in a Part D plan. This level of “extra help” also allows the

ability to change plans every quarter up to the first three quarters (January-March,

April-June, or July-September) if necessary.

D. Low Income Subsidy (LIS or “Extra Help”)

1. Assistance in paying for the Medicare Prescription Drug

coverage (stand-alone plan or Medicare Advantage plan) is

available to those with limited income and assets who qualify.

Extra Help greatly reduces prescription drug co-payments.

Depending on people’s income and asset levels, they may

qualify for more or less assistance. (See Chart for more detailed information.)

2. Beneficiaries using other low-income assistance programs (food stamps, housing

assistance, etc.)

a. Enrollment in the Medicare Prescription Drug LIS will likely impact their current

level of assistance from these programs.

b. These programs take into account the amounts spent on prescription medications.

Enrollment in the LIS should greatly decrease the amount they are paying out of

pocket, thus decreasing their assistance levels with the other programs.

c. Savings from LIS is usually greater than the loss of the other assistance.

3. Plans that qualify for full premium coverage through LIS or Extra Help are:

a. Standard or Basic plans offered by a Prescription Drug Plan/Medicare Advantage

Plan with drug coverage

b. Below the region’s average yearly premium.

See Money

Tip Sheet!

See Money

Tip Sheet!

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Example: Company Green offers three plans here in Missouri with three different premiums of

$10.29; $16.36; and $56.43. Extra Help will only pay the full premium for the $10.29 Standard Plan.

If a beneficiary with extra help joins the $56.43 plan, they must pay the difference in premiums

$56.43 - $10.29 = $46.14

4. Extra help will only pay the premiums for the drug coverage. If a beneficiary enrolls

in a Medicare Advantage plan with drug coverage with a premium he/she will still

have to pay the premium for the medical coverage.

Example: Sally Jones enrolls in the Purple Horizons Advantage Plan with Prescription Drug

coverage. It has a monthly premium of $40 for the medical coverage portion and $15 for the drug

coverage or $55 total monthly premium. Sally is a dual-eligible and thus qualifies for full extra help

benefits for the prescription drug coverage. So her extra help will pay the $15 drug coverage

premium only. She must pay the health plan premium.

5. Individuals with Extra Help are still bound by all the same rules as those beneficiary’s

without extra help including:

a. Pre-certification rules

b. Excluded drugs

c. Quantity limits

d. Formulary rules

e. Step therapy

6. Limited Income Newly Eligible Transition Program (LINet) – is designed to

eliminate gaps in coverage for low-income individuals transitioning to Medicare Part

D coverage.

This program is designed to help ensure that individuals with Medicare’s low income

subsidy (LIS), or “Extra Help,” who are not yet enrolled in a Part D prescription drug

plan are still able to obtain immediate prescription drug coverage. This includes:

Beneficiaries with Medicare and MO HealthNet (Medicaid), or dual-eligible

Those with Medicare who also receive Medicare’s low income subsidy

Medicare contracts with a Medicare Prescription Drug Plan company to provide this

service. Included at the end of Part D chapter are the LI Net instructions that can be

shared with pharmacies to help get a beneficiary their medications if necessary.

Example: Mrs. Simpson has been on MO HealthNet benefits for the last two years due to a

disability. Her Medicare benefits started last month. She did not realize she needed to join a Part D

plan until she went to the pharmacy last month and was told she did not have any coverage for

medications. Since she did not choose a Part D plan, Medicare has enrolled her into a plan that will

not take effect until next month. The pharmacist should use the LINet Program to provide coverage

for Mrs. Simpson medications for last month and this month until the plan Medicare has enrolled her

in takes effect the first of next month. Mrs. Simpson will still owe the appropriate co-pays for her

medications.

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E. Missouri Rx (MORX) - Missouri’s State Pharmacy Assistance Program

(SPAP)

1. Missouri RX coverage works with your Medicare Prescription Drug coverage

(standalone plan or Medicare Advantage plan).

2. MORX eligibility: Medicare beneficiaries must have MO HealthNet (dual eligible)

to be in the program. This includes Medicare beneficiaries with full Medicaid

benefits and those with a Medicare Savings Program (QMB, SLMB or QI-1) or have

an open spend down case.

3. MORX enrollment: Medicare beneficiaries will automatically be enrolled in MORX

when they first have MO HealthNet. They should receive a letter and member card

from MO HealthNet.

4. MORX benefits: The program pays 50% of all drug plan copays, including during the

coverage gap. If a beneficiary has a spend-down case, they must meet the spend-

down amount at least once in a calendar year to receive the 50% benefit. If they do

not meet their spend-down amount, MORX will only pay a small flat amount per

prescription.

5. MORX benefit requirements: The beneficiary must use a Missouri pharmacy and the

prescription can only be for a 30/31 day supply. The medication must be on the

plan’s formulary or have a coverage exception. MORX is not accepted at all

pharmacies.

6. MORX will not cover purchases from a mail-order pharmacy.

7. MORX will not cover drug plan premiums.

8. The 50% benefit of MORX is not reflected in the drug costs in the plan finder tool of

Medicare.gov

9. MORX help desk phone number is 800-375-1406.

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VIII. Section 8 Review

PUBLIC BENEFITS AND MEDICARE REVIEW

1. What is SSI, who administers it, and who is it for?

2. What are the income and resource limits for SSI?

3. What is the difference between Medicare and MO HealthNet (Medicaid)?

4. Who determines eligibility and accepts applications for MO HealthNet (Medicaid)?

5. What are the allowed exclusions for MO HealthNet beneficiaries?

6. If a Medicare beneficiary is MO HealthNet eligible who would be the primary payer for the medical

bills?

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7. What do QMB and SLMB stand for? What do they do for the beneficiary? What are the eligibility

requirements?

8. If a Medicare beneficiary is eligible for QMB, do they need to continue to pay for their supplemental

insurance policy? Explain why or why not. Are there any other options?