Two New California Insurance policies Simplify Entry to Medicare Monetary Help

Beginning January 1, 2025, two new insurance policies shall be carried out to enhance enrollment in California’s Medicare Financial savings Applications, making Medicare extra reasonably priced by offering help with out-of-pocket prices resembling premiums, co-pays, co-insurance, and deductibles for low-income people.

Medicare Half A Purchase-In: Efficient January 1, 2025, California will convert from a gaggle payer state to a Medicare Half A buy-in state.^[1] This variation simplifies enrollment within the Certified Medicare Beneficiary (QMB) program, which covers the Medicare Half A premium for many who should not eligible for premium-free Half A.
Computerized Enrollment into QMB for SSI Recipients: California will instantly enroll Supplemental Safety Revenue (SSI) recipients into the QMB program. This computerized course of will facilitate enrollment into Half A for these individuals who have a premium, if they aren’t already enrolled.

Collectively, these coverage modifications will take away administrative boundaries that at present impede enrollment into Medicare Half A and the QMB program, making it simpler for eligible people to get help with Medicare prices. By way of the QMB program, enrollees not solely get assist with month-to-month premiums, additionally they obtain cost-sharing help and are shielded from improper billing.

For an in-depth evaluation of Half A Purchase-In, see Justice in Getting old’s subject transient: Constructing the Path to Medicare Half A Purchase-In. See additionally Justice in Getting old’s tip sheet on Medicare Conditional Half A Purposes.

The Certified Medicare Beneficiary Program

Each coverage modifications simplify enrollment into the Certified Medicare Beneficiary (QMB) program. QMB is a Medi-Cal program that gives monetary help with Medicare prices to people with incomes under 100% of the federal poverty stage. As a QMB enrollee, Medi-Cal pays the Half A premium (when relevant), the Half B premium, in addition to all Medicare deductibles, co-pays, and co-insurance. The QMB program may even get rid of any late enrollment penalties that may have accrued for delaying Half A or Half B enrollment.^[2] As well as, Medicare suppliers can not cost QMBs for any quantities past what Medicare and Medi-Cal pay; QMBs are shielded from improper billing below federal legislation.

Coverage Change: Conversion to Medicare Half A Purchase-In

Who’s Impacted?

Half A buy-in will make enrollment into the QMB program easier for low-income folks eligible for Medicare, however who should not eligible totally free Half A as a result of they don’t have sufficient qualifying work historical past. QMB is the one Medi-Cal program that pays for Half A premiums. The individuals who don’t qualify totally free Half A, referred to as “Half A with a premium,” are sometimes ladies, older immigrants, and extra prone to be Asian American/Pacific Islander, Black, or Hispanic.^[3]

What Will the Conversion Change in California?

Right now, folks with out free Half A face overly sophisticated enrollment guidelines. It is because California is at present a gaggle payer state. As a gaggle payer state, folks with out free Half A are at all times required to file an utility for conditional Half A enrollment with the Social Safety Administration (SSA) area workplace earlier than they will apply for QMB with their county to obtain Medi-Cal fee of Half A premiums. Moreover, these functions can solely be submitted in a three-month window, January to March. If people miss this window, they have to wait till the following 12 months. These sophisticated enrollment guidelines for Half A and QMB apply to people who find themselves not eligible totally free Half A and didn’t enroll once they first turned Medicare eligible. In 2021, greater than 181,000 folks owed a premium for Half A in California.^[4]

In distinction, Medicare Half A Purchase-In is an settlement between California and SSA that offers qualifying folks the choice to enroll in Half A with a premium outdoors of standard Medicare enrollment durations. By way of buy-in, folks can enroll into Half A with a premium year-round. California is changing from a gaggle payor state to a Half A buy-in state in January 2025.

For folks already enrolled in Medicare Half B, Half A buy-in will get rid of the necessity to apply for Half A with a premium individually on the SSA. They may solely want to use for QMB at their county workplace (or may even be routinely enrolled in QMB – see under for computerized QMB enrollment modifications). For individuals who haven’t but established Medicare eligibility, they’ll nonetheless want to use for conditional Half A at SSA, however can accomplish that at any time of the 12 months after which enroll in QMB with their county workplace. As soon as enrolled in Half A, they’ll obtain a brand new Medicare card indicating Half A protection.

By enrolling into Half A, folks will change into full dually eligible people with each Components A and B. Medicare shall be major for almost all of their medical care. Full dually eligible people even have the choice of becoming a member of a Twin Eligible Particular Wants Plan (D-SNP) and may contact their native Well being Insurance coverage and Counseling Program totally free Medicare counseling to find out if that is the best selection for them.

Advocacy Tip

Regardless of the enhancements by Half A buy-in, communication between the SSA and Medi-Cal places of work should not at all times seamless. For individuals who want to determine Medicare entitlement and apply for Half A with a premium, advocates ought to nonetheless instruct purchasers to acquire a receipt or proof of their Conditional Half A enrollment from the SSA workplace. Written proof, resembling a screenshot of the affirmation web page or receipt, might be submitted alongside their QMB utility.

Coverage Change: Computerized Enrollment of SSI Recipients into QMB

Below a brand new federal legislation, California can be required to routinely, or instantly, enroll SSI recipients into the QMB program.^[5] SSI recipients are both over 65, blind, or have a incapacity, have restricted earnings and belongings, and obtain month-to-month money funds from SSA. This new coverage will solely impression these SSI recipients which can be age 65 and over as a result of they’re those eligible for Medicare at age 65. Individuals who obtain SSI routinely obtain Medi-Cal (sometimes called “SSI-linked Medi-Cal”) and are routinely enrolled in Half B through Half B buy-in. The automated enrollment into QMB for SSI recipients shall be performed in two phases:^[6]

Beginning October 1, 2024, California will routinely enroll present SSI-linked Medi-Cal people who’re eligible totally free Half A into the QMB program. New SSI recipients eligible totally free Half A may even be routinely enrolled into QMB. Eligible people should not have to submit a separate QMB utility on the Medi-Cal workplace.
Beginning January 1, 2025, California will routinely enroll all SSI-linked Medi-Cal people into QMB, no matter their Half A premium standing. Eligible people don’t must submit a separate QMB utility with the Medi-Cal workplace. The January 1^st coverage change is extra expansive because it contains low-income Californians on SSI who’re ineligible totally free Half A.

The automated enrollment into QMB applies to SSI recipients solely. It is because all folks with SSI advantages are eligible for the QMB program as a result of the SSI profit quantity is decrease than the QMB earnings restrict of 100% FPL ($1,255/single particular person in 2024). Non-SSI recipients enrolled in Medicare should proceed to submit QMB functions with the Medi-Cal workplace.

California will mail Notices of Motion notifying people they’ve been routinely enrolled into the QMB program.^[7] They don’t must take any additional motion. If advocates help SSI-linked Medi-Cal purchasers who meet the standards for computerized QMB enrollment however should not enrolled in QMB, please contact Justice in Getting old.

New Enrollment Steps Below These Coverage Adjustments

The steps folks might want to take because of these coverage modifications is dependent upon whether or not they have SSI or their Half B enrollment standing:

People eligible for Medicare and never receiving SSI:

Non-SSI People already enrolled in Half B: They don’t want to use for Conditional Half A on the SSA workplace. They will apply for QMB and, if eligible, California will enroll them into Half A and provoke state fee of their Half A premium.
Non-SSI people not but enrolled in Half B: This group should set up entitlement to Medicare and apply for Half B and Conditional Half A with SSA first. After this step, they will apply for QMB on the Medi-Cal workplace. After January 1, 2025, the applying for Conditional Half A might be submitted year-round below the brand new buy-in coverage.

SSI recipients eligible for Medicare:

Beginning October 1, 2024: SSI-linked Medi-Cal people enrolled in free Half A shall be routinely enrolled into QMB by the state. This contains present and new SSI recipients.
Beginning January 1, 2025: All SSI-linked Medi-Cal people shall be enrolled in QMB and if wanted, Half A. This contains present and new SSI recipients.

Efficient Dates: Half A buy-in begins the identical month that QMB protection is efficient, which is the next month after an individual’s eligibility for QMB is permitted.^[8] For instance, if Jim’s QMB utility is permitted as of January 1, 2025, his efficient date for QMB protection and Half A is February 1, 2025. California is liable for paying the Half A premium starting February 2025. Even when there are delays processing a QMB utility, the efficient QMB date is retroactive to the primary of the next month after the QMB approval date.

Late Enrollment Half A Penalties are Erased

Below a Half A Purchase-In settlement, CMS waives the late enrollment penalties for any QMB enrollee who didn’t enroll throughout their preliminary enrollment interval.^[9] If an individual later loses QMB eligibility, late enrollment penalties is not going to reappear as soon as the particular person begins paying the Half A premiums on their very own.^[10] Half A late enrollment penalties can solely be eradicated by the QMB program. Half B late enrollment penalties are eradicated through California Half B buy-in.^[11]

Instance: An older grownup who shouldn’t be enrolled in both Half A with a premium or Half B in April 2025 and doesn’t have Medi-Cal.

Maria is age 67 and doesn’t qualify totally free Half A. Maria can be not enrolled in Half B. Maria contacts the Medi-Cal workplace to use for the QMB program. The Medi-Cal workplace instructs her that as a situation of enrolling in QMB, she should set up eligibility for Medicare by making use of on the SSA workplace. Maria applies for Half B and Conditional Half A on the SSA workplace. As a result of CA is now a Half A buy-in state, the Conditional Half A utility might be filed at any time of the 12 months. After she applies for Half B and Conditional Half A, Maria goes to the Medi-Cal workplace to use for QMB the identical month. If permitted for QMB, CA will provoke buy-in and pay for her Half A and B premiums. If she shouldn’t be permitted for QMB, her Half A enrollment shall be cancelled. Maria can even take into account making use of for full Medi-Cal advantages past QMB.

Advocacy Tip

Advocates ought to inform their purchasers to particularly ask to be enrolled in Half A with a premium “conditionally” and to quote to or print out the SSA Program Operations Guide System (POMS) part HI 00801.040 that offers SSA employees exact directions to make sure the conditional Half A is dealt with accurately.

Learn Extra in Justice in Getting old’s factsheet, Medicare Half A Conditional Purposes.

Instance: An older grownup is enrolled in Half B however not enrolled in Half A with a premium in April 2025.

Daniel has Medicare Half B solely and isn’t eligible totally free Half A. Daniel needs to enroll in Half A with a premium and learns he can get assist by the QMB program for the premium. Since California is now a Half A buy-in state, Daniel doesn’t want to use for Half A since he’s already enrolled in Half B and has established his Medicare eligibility. Daniel can apply for the QMB program on the Medi-Cal workplace and if discovered eligible, California will enroll him into Half A with a premium and pay his Half A premiums.

Instance: An older grownup with SSI advantages is popping 65 in March 2025 and doesn’t qualify totally free Half A.

Anna has SSI-linked Medi-Cal. As a result of she has SSI-linked Medi-Cal, she is enrolled in Half B through Half B buy-in as of March 1, 2025 and into QMB. Her Half A and QMB protection, together with QMB cost-sharing protections begins the next month on April 1, 2025.

Present QMB Enrollees Do Not Must Take Motion

People at present on QMB and already receiving state fee of Half A premiums don’t must take any motion. California will proceed to pay their Half A premiums – the one change is the strategy utilized by the state to pay the premiums to SSA. Usually, this transition would set off a written discover of the change in fee standing however CMS is suppressing these notices due to pointless confusion. If advocates hear of misguided notices, please contact Justice in Getting old. CMS needs to know if these notices happen.

When you have questions or hear of incorrect data relating to Half A enrollment, please contact Tiffany Huyenh-Cho at Justice in Getting old at thuyenhcho@justiceinaging.org.

Steps People Must Take Below These Two New Insurance policies^[12]

Group	Efficient Date	Particular person should apply for Conditional Half A	Particular person should apply for Half B	Particular person should apply for QMB	State instantly enrolls into QMB	Notes
SSI-linked Medi-Cal people eligible totally free Half A	10/1/2024	N/A	N/A	N/A	YES	Will get Medicare card if newly enrolled into Half A
All SSI-linked Medi-Cal people (with free Half A or Half A with a premium)	1/1/2025	N/A	N/A	N/A	YES	Will get Medicare card if newly enrolled into Half A
People with out SSI enrolled in Half A with a premium and Half B	1/1/2025	N/A	N/A	YES	N/A	If permitted for QMB, State begins fee of Half A premium
People with out SSI enrolled in Half B and eligible for Half A with a premium, however not enrolled	1/1/2025	N/A	N/A	YES	N/A	If permitted for QMB, State initiates Half A buy-in
People with out SSI who should not enrolled in both Half A with a premium or Half B	1/1/2025	Elective	YES	YES	N/A	If permitted for QMB, State begins fee of Half A premium

Endnotes

Welf. and Establishment Code §14005.11. ↑
Individuals who delay enrollment into Half A or B once they first change into Medicare eligible can face increased month-to-month premium funds as a result of penalties added on to the usual premium quantity. As a buy-in state in 2025, SSA will waive state fee of late enrollment penalties for Half A. See 42 CFR 406.26(a)(2). Half B penalties are additionally waived below the Half B buy-in settlement. 42 CFR 407.50(a). ↑
CMS Program Statistics – Medicare Premiums, MDCR Premiums 2 tab, 2021, accessed October 25,2024 ↑
CMS Program Statistics – Medicare Premiums, MDCR Premiums 3 tab, 2021, accessed October 25,2024 ↑
As a brand new Half A buy-in state, California is required to enroll eligible SSI people into QMB. 42 C.F.R. § 435.909. ↑
DHCS, Medi-Cal Eligibility Division Data Letter (MEDIL) 24-17 (August 28, 2024). ↑
For a replica of the written discover, see MEDIL 24-17. ↑
Title 22 California Code of Laws (CCR) §50258(b). ↑
42 CFR 406.26(a)(2). ↑
See 42 CFR 406.26(d)(1)(i); Guide for State Fee of Medicare Premiums, Chapter 1: Program Overview and Coverage, Part 1.15. ↑
42 CFR 407.50(a); Medi-Cal Eligibility and Procedures Guide Article 15, Chapter 15F; MEDIL 21-05 (March 12, 2021). ↑
It’s at all times elective for folks to enroll in Half A in the event that they owe a premium for Half A. ↑