Section 210-RICR-40-05-1.6 - The Medicare Premium Payment Program (MPPP)1.6.1Scope and PurposeA. The Medicare Premium Payment Program (MPPP) helps low-income elders sixty-five (65) and older and adults with disabilities pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments.1. Basis of Eligibility - A person's income and resources, as calculated using the SSI methodology, determine which type of Medicare premium assistance is available. Members of this coverage group are known as "dual eligible," as they qualify for both Medicare and Medicaid, as defined below: a. Dual eligible beneficiaries who qualify for the MPPP, but not full Medicaid health coverage are referred to as "partial dual eligible" beneficiaries.b. Dual eligible beneficiaries who meet the all the eligibility requirements for an IHCC or MACC group and are enrolled in Medicare Part A and Part B are known as "full dual eligible beneficiaries."c. Dual eligible beneficiaries who receive Medicaid health coverage through the MN pathway, and meet the income requirements for the MPPP, are referred to as "partial dual eligible plus beneficiaries."2. Medicare Coverage and the MPPP - Medicare provides the following types of coverage:a. Medicare Part A. Pays for hospital services and limited skilled nursing services. Medicare Part A is provided at no-cost to a person who: is insured under Social Security or Railroad Retirement Systems (e.g., paid into the system for forty (40) quarters of work) and sixty-five (65) years of age; has reached the twenty-fifth (25th) month of a permanent and total disability; or received continuing kidney dialysis or had a kidney transplant. Under an agreement with the SSA, the State is authorized to purchase Part A through the MPPP for persons who are elderly or living with a disability who do not qualify for no-cost Part A coverage.b. Medicare Part B. Pays for physician services, durable medical equipment and other outpatient services. Medicare Part B is available to persons who pay a monthly premium and are sixty-five (65) years of age or older without regard to whether they are insured in the Social Security or Railroad Retirement Systems as well anyone who has reached the twenty-fifth (25th) month of a permanent and total disability. Initial enrollment is a seven (7) month period that starts three (3) months before a person first qualifies for Medicare and extends three months past the sixty-fifth (65th) birthday or, if failing to enroll during this period, through an open enrollment period held each year from January through the end of March. The State pays the Part B premium for Medicare beneficiaries eligible through all of the MPPP eligibility pathways listed below.c. Medicare Part C. Medicare managed care ("Advantage" plans) provide Medicare Part A, Part B and Part D (prescription drug coverage) for beneficiaries who qualify.d. Medicare Part D. Pays for prescription drug coverage for enrolled Medicare beneficiaries. Costs for beneficiaries vary. Low-income Medicare beneficiaries who qualify for the Federal government's Extra Help program, which provides assistance in paying the costs for Part D, are automatically eligible for the MPPP. The SSA provides electronic notification to the States of Medicare beneficiaries who are eligible for the MPPP on this basis.e. Medicaid wraps around Medicare's coverage by providing financial assistance to beneficiaries in the form of payment of Medicare premiums and cost-sharing, as well as coverage of some benefits not included in the Medicare program. Not all dual eligible beneficiaries receive the same level of Medicaid benefits, as indicated below.1.6.2MPPP Eligibility PathwaysA. The specific eligibility requirements and benefits coverage groups included in the MPPP pathway are as follows: 1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - Financial assistance in this group is provided to beneficiaries who are eligible for or enrolled in Medicare Part A, have countable income of one hundred percent (100%) of FPL or less and resources that do not exceed the amounts set annually by the Federal government (see §1.6.5 of this Part). For partial dual eligible QMBs:a. Medicaid makes a direct payment to the Federal government for the Part A premium (if any), the Part B premium, and provides payments for Medicare co-insurance and deductibles as long as the total amount paid by Medicare does not exceed the amount Medicaid allows for the service.b. Eligibility begins on the first (1st) day of the month after the application is filed and all eligibility requirements are met.c. Eligibility is renewable in twelve (12) month periods.d. Deeming rules do not apply.e. There is no retroactive coverage.2. QMBs with Medicaid health coverage (QMB Plus) - Persons who qualify through this pathway must be entitled to Medicare Part A, have countable income at or below one hundred percent (100%) of the FPL, and resources at four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a couple. Beneficiaries eligible through this pathway are full dual eligible beneficiaries and receive premium assistance and Medicaid health coverage. Includes MN Medicaid beneficiaries. Access to Medicaid retroactive coverage, continuing eligibility, and the full scope of Medicaid essential benefits is available.3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have countable income of greater than one hundred percent (100%) FPL, but less than one hundred twenty percent (120%) FPL, resources within the federally defined limits, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.a. Medicaid pays the Medicare Part B premium to SSA.b. Eligibility begins on the first (1st) day of the month in which the application is filed and all eligibility requirements are met.c. Eligibility is authorized for a twelve (12) month period and is renewable on that basis.d. Deeming rules do not apply.e. Retroactive coverage may be available.4. SLMBs with Medicaid health coverage (SLMB Plus) - To be eligible through this pathway, a person must be entitled to Medicare Part A, have countable income of greater than one hundred percent (100%) FPL but less than one hundred twenty percent (120%) FPL, and resources of no more than four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) a couple. A person qualifies for Medicaid through this pathway only if MN requirements are met. In addition to full Medicaid essential benefits, the MPPP also pays the beneficiary's Medicare Part B premiums, coinsurance, deductibles and copayments.5. Medicaid pays the SSA. Community Medicaid EAD general eligibility requirements govern access to Medicaid retroactive coverage, continuing eligibility, and scope of coverage.6. Qualified Disabled and Working Individuals (QDWIs) - This pathway covers beneficiaries who lost their Medicare Part A benefits due to their return to work. They must be eligible to purchase Medicare Part A benefits, have countable income of two hundred percent (200%) FPL or less and resources that do not exceed twice the limit for SSI eligibility EAD limits of four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a couple), and must not be otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. a. Medicaid makes a direct payment to the SSA for the Part A premium;b. Eligibility begins the month in which all requirements are met, including enrollment in Part A, and continues for a year unless or until changes in employment result in resumption of Medicare without MPPP assistance.7. Qualifying Individuals-1 (QI-1) - To qualify for eligibility through this pathway, beneficiaries must be entitled to Medicare Part A, have countable income of at least one hundred twenty percent (120%) FPL, but less than one hundred thirty-five percent (135%) FPL, resources that do not exceed the amounts set by the Federal government (see §1.6.5 of this Part), and be otherwise ineligible for Medicaid. Medicaid pays Medicare Part B premiums only. Federal matching funds for members of this group is one hundred percent (100%) and, as such, the availability of financial assistance through QI-1 eligibility is contingent on Federal appropriations. For members of this group: a. Medicaid makes a direct payment to the SSA for the Part B premium.b. Eligibility begins the month in which the application is filed and all requirements are met and ends on December thirty-first (31st) of the year in which the application is filed.c. Cost-of-living increases in Title II benefits (COLAs), effective in January each year, are disregarded in determining income eligibility through the month following the month in which the annual Federal Poverty Guideline update is published.e. Retroactive coverage may be available. Retroactive eligibility (of up to three (3) calendar months prior to application) applies if the individual met all QI eligibility criteria in the retroactive period, and the retroactive period is no earlier than January 1st of that calendar year.8. MN and QMB (+) and SLMB (+) - Participation in the MPPP may adversely affect the income eligibility of a person seeking initial or continuing Medicaid health coverage through the MN pathway. As the State pays some or all Medicare costs for MPPP participants, these allowable health expenses cannot be counted toward a MN spenddown. This, in turn, may make it difficult to obtain Medicaid health coverage for high costs services that are covered only in part or not at all by Medicare. MPPP enrollment may also affect other forms of Medicaid eligibility if it changes the way income or resources are counted. An agency eligibility specialist should be consulted by an applicant or beneficiary who is concerned that enrolling in the MPPP will affect access to Medicaid health coverage. 1.6.3MPPP Application ProcessA. There are multiple application pathways for pursuing MPPP eligibility. 1. MPPP - Persons seeking MPPP coverage may apply through the State or the SSA. If applying through the State's IES, a person has the option of applying for the MPPP only or Medicaid health coverage and the MPPP.2. LIS and Social Security Administration (SSA) - An application for the LIS program is available online at: https://secure.ssa.gov/i1020/start or by calling 1-800-772-1213 or TTY 1-800-325-0778, Monday-Friday, 7 a.m. - 7 p.m. The State uses information provided by the SSA for determining LIS eligibility to initiate an application for the MPPP, when appropriate.1.6.4MPPP Eligibility and Continuing EligibilityPersons seeking MPPP assistance are subject to the SSI-methodology for determining financial eligibility, though the income and resources standards specific to the MPPP coverage group, as indicated in § 1.6 of this Part, are applied. A disability determination is not required for MPPP financial help only. With the implementation of the State's IES, continuing eligibility is determined using a modified passive renewal process (See §00-2.7.2(A)(5) of this Chapter).
1.6.5MPPP SummaryA. The following provides a summary of the MPPP eligibility pathways by coverage group that shows financial eligibility limits as of January 1, 2023 and the benefits provided: MPPP Eligibility Pathways |
Coverage Group | Full or Partial Eligible | Income and Resource Limits Individual/Couple | Benefits |
QMB | Partial Dual | 100% FPL All MPPP applicants receive a $20.00 income disregard. $9,090.00 - Individual $13,630.00 - Couple | Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part A premiums (if needed) Medicare Part B premiums Certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program) |
QMB+ | Full Dual | 100% FPL $4,000.00 / $6,000.00 | All of the above AND Medicaid health coverage |
SLMB | Partial Dual | 101% - 120% FPL $9,090.00 - Individual $13,630.00 - Couple | Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part B premiums |
SLMB + | Full Dual | 101% - 120 % FPL $4,000.00 / $6,000.00 | Same as above AND: Certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program) Full Medicaid Coverage |
QI | Partial Dual | 121% - 135% FPL $9,090.00 - Individual $13,630.00 - Couple | Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part B premiums |
QWDI | Partial Dual | 200% FPL $4,000.00 - Individual $6,000.00 - Couple | Lost Medicare Part A benefits because of return to work but eligible to purchase Medicare Part A and qualify for Medicaid payment of: Medicare Part A premiums |
210 R.I. Code R. § 210-RICR-40-05-1.6
Amended effective 11/5/2020
Amended effective 6/3/2021
Amended effective 4/9/2023
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/27/2023