Frequently Asked Questions:
Medicare Part A Buy-In as of January 1, 2025
Background:
Effective January 1, 2025, California is a Medicare Part A Buy-In State. Under the Medicare Part A Buy-In agreement with the Centers for Medicare & Medicaid Services (CMS), eligible full-scope Medi-Cal members who are enrolled in Medicare Part B, if they qualify for the Qualified Medicare Beneficiary (QMB) program, can be automatically enrolled in Medicare Part A Buy-In by the Department of Health Care Services (DHCS). The state will pay their Medicare Part A premiums. Following the Medicare Part A Buy-In enrollment, these QMB Medi-Cal members will become dually eligible for Medicare and Medi-Cal.
More specifically, as of January 1, 2025, eligible Supplemental Security Income/State Supplementary Payment (SSI/SSP) full-scope Medi-Cal members are automatically enrolled in Medicare Part A if they are enrolled in Medicare Part B and qualify for the QMB program. Conditional Medicare Part A enrollment requirements are no longer applicable.
Similarly, non-SSI/SSP eligible Medi-Cal members who enroll in Medicare Part B at the SSA can apply for the QMB program at their local county office. Once they qualify for the QMB program, the state will enroll them in Medicare Part A Buy-In. All Medi-Cal members enrolled in the QMB program will receive an approval Notice of Action in the mail informing them of their QMB program enrollment effective date.
Question 1: What does the Medicare Part A Buy-In mean for Medi-Cal members who currently have Medicare Part B only?
From a member perspective, this means that if the QMB Medi-Cal member is eligible for Medicare Part A Buy-In, Medicare, instead of Medi-Cal, will provide primary coverage for hospitalizations and other inpatient benefits that are covered through Medicare Part A.
Question 2: Does Medicare Part A Buy-In impact people who already have both Medicare Part A and Part B?
No, this does not change coverage or eligibility for people who already have both Medicare Part A and Part B.
Question 3: What notices are being sent to members for Medicare Part A Buy-In?
When a QMB Medi-Cal member is approved for the Medicare Part A Buy-In due to their enrollment in Medicare Part B at the SSA, they will receive a QMB approval notice in the mail. This notice will inform them of the effective date of their QMB program.
SSA will send a notice to let Medi-Cal members know when the State of California starts to pay their Medicare Part A hospital insurance premium.
Question 4: Who can members contact if they have questions?
For member questions regarding access to care, please contact your Medi-Cal Managed Care Plan (MCP). For member questions regarding Medicare eligibility, please contact your local Social Security Administration office or the Health Insurance Counseling & Advocacy Program (HICAP). For questions about QMB, please call the Medi-Cal Helpline at (800) 541-5555.
Question 5: What qualifications are needed to be eligible for the Medicare Part A Buy-In?
Under the Medicare Part A Buy-In agreement with CMS, as of January 1, 2025, a full-scope Medi-Cal member must be enrolled in Medicare Part B and qualify for the QMB program before they can be eligible for the Medicare Part A Buy-In.
The department will:
- Auto-enroll all eligible SSI/SSP Medi-Cal members into the Medicare Part A Buy-In if they are enrolled in Medicare Part B and qualify for QMB.
- Enroll non-SSI/SSP Medi-Cal members into the Medicare Part A Buy-In if they are enrolled in Medicare Part B and qualify for the QMB program. Non-SSI/SSP Medi-Cal members must apply for Medicare Part B at the SSA before they can be enrolled in the QMB program and Part A Buy-In.
All SSI/SSP individuals will be QMB+ as of January 1, 2025. QMB-eligible individuals will be enrolled in Medicare Part A Buy-In starting January 1, 2025. Medicare Part A Buy-In would apply to members eligible for both QMB and QMB+ programs.
To qualify for the QMB program, an individual must meet the following criteria:
- Be eligible for Medicare Part A and B,
- Meet the net countable income requirements of at or below 100% of the Federal Poverty Level (FPL), and
- Meet other Medi-Cal eligibility requirements.
Question 6: What aid codes are impacted?
As of January 1, 2025, DHCS will facilitate and ensure the seamless enrollment of active SSI individuals into the QMB program. DHCS will automatically assign the QMB aid code (80) to individuals enrolled in the SSI program in addition to their primary aid codes (10, 20, or 60).
California will be a Medicare Part A Buy-In state as of January 1, 2025. If eligible Medi-Cal members qualify for the QMB program (aid code 80), DHCS can enroll them in Medicare Part A and pay their premiums.
Question 7: How can Medi-Cal Managed Care Plans (MCPs) help their members maintain access to care for the Medicre Part A Buy-In?
DHCS encourages MCPs to use the Medicare Part A and B indicators available through the 834 Managed Care Enrollment file to identify members with Medicare Part B only and take any needed steps to provide a smooth transition for inpatient care that may be currently covered by Medi-Cal, but will be covered by Medicare effective January 1. MCPs have a responsibility to continue coordination of benefits but not hinder access to care.
DHCS also notes that MCPs with aligned Dual Eligible Special Needs Plans (D-SNPs) are permitted by federal regulations to outreach to these soon-to-be full-benefit dually eligible members regarding enrollment in Medi-Medi Plans, per 42 CFR 422.2264(b).
Question 8: Are any changes needed to D-SNP member materials?
Medi-Medi Plans do not need to update the integrated member materials related to Medicare Part A Buy-In. The Medicare Part A Buy-In does not impact members who already have Medicare Part A and B, as only those with both Medicare Part A and B can enroll in D-SNPs. The members impacted by the Medicare Part A Buy-In are not enrolled in D-SNPs.
Question 9: Can the Department confirm that the NOA and the letter listed in bullets below are intended for use in place of any other NOA needed for pending prior authorizations that may be transferred to the Medicare payer?
The SSI QMB Approval Notice of Action (NOA) and the SSI QMB transfer letter described below inform the Qualified Medicare Beneficiary (QMB) member about either their enrollment in the QMB program or share information about the QMB program. They are not intended to replace any other NOA needed for pending prior authorizations that may be transferred to the Medicare payer.
- SSI QMB Approval Notice of Action (NOA) - informs Supplemental Security Income (SSI) and State Supplemental Payment (SSP) Medi-Cal members who are eligible for “premium-free Medicare Part A” about their Qualified Medicare Beneficiary (QMB) program automatic enrollment start date and provides information about the QMB program.
- SSI QMB Transfer Letter - informs SSI/SSP Medi-Cal members, who will be automatically enrolled in the QMB program under SB 311 and the CMS Final Rule starting in January 2025, about a new contact for any questions regarding the QMB program. This letter also includes information about the QMB program.
Question 10: Does the Department have any guidance to support Plans in defining the scope of Medicare Part A? Is there a definition or guidance the Plan should align to as we address existing prior authorizations?
Medicare, instead of Medi-Cal will provide primary coverage for hospitalizations and other inpatient benefits that are covered through Medicare Part A. For more information on Medicare Part A and what it helps pay for, please refer to this webpage and Medicare.gov.
Question 11: Further, yet related, the Plan will need to distinguish between inpatient, outpatient, and observation. Is there a definition of "Inpatient" that the Plan should align with? Are observation stays included in inpatient? Is surgery performed within a hospital surgery center considered outpatient?
For more information on Medicare inpatient care services, please refer to this webpage and Medicare.gov.
Question 12: When can members expect to start receiving Medicare Part A Buy-In communication, and who will be responsible for sending it?
The individuals enrolled in the QMB program will receive communication from DHCS by mail as follows:
- Newly eligible QMB members who receive Supplemental Security Income (SSI) and State Supplemental Payment (SSP) and who are enrolled in free Medicare Part A can expect to receive the QMB Approval Notice of Action in the mail between October and December 2024.
- SSI/SSP Medi-Cal members who are enrolled in Medicare Part B and qualify for the QMB program but who did not previously have Medicare Part A will be enrolled in Medicare Part A Buy-In and QMB program by the state. This change will be effective January 2025, and these QMB members will receive the SSI QMB Transfer letter in late January or early February 2025.
- Those who do not receive SSI/SSP and apply for the QMB program through the county will continue to receive the existing QMB Approval Notice of Action (NOA) if approved.
- The Social Security Administration (SSA) will send a letter when an individual is new to Medicare Part A Buy-In.
Question 13: What are the specific eligibility criteria for individuals to qualify for the Medicare Part A premium payment?
To be eligible for Part A premium payment (Buy-In), an individual must meet the following criteria:
- Are enrolled in the Qualified Medicare Beneficiary (QMB) program, and
- Have Medicare Part B entitlement as reported by the Social Security Administration (SSA).
To qualify for the QMB program, an individual must meet the following criteria:
- Be eligible for Medicare Parts A and B.
- Meet the net countable income requirements of below 100% of the Federal Poverty Level (FPL) and
- Meet other Medi-Cal eligibility requirements.
Question 14: Is there anything these members need to do proactively to ensure they qualify for the Medicare Part A premium payment?
To ensure that QMB members continue to qualify for the Medicare Part A Buy-In, which allows the state to pay their Medicare Part A premium, they must maintain their full-scope Medi-Cal coverage and Medicare Part B eligibility. Additionally, it is important for those receiving SSI/SSP benefits to maintain their eligibility for SSI/SSP as well.
As of January 1, 2025, eligible SSI/SSP full-scope Medi-Cal members will be automatically enrolled in Medicare Part A if they are enrolled in Medicare Part B and qualify for the QMB program. Conditional Medicare Part A enrollment requirements are no longer applicable.
Similarly, the non-SSI Medicare eligible members will only be required to complete an MSP and/or Medi-Cal application with the county Medi-Cal office and qualify for the QMB program.
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