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Revision: HCFA-PM-93-5 MB)PfAY lq93State C L I F O R N I

Citation

1902 a) lO) E) i) and1905 p) l) of the Act

3 2 coordination of Medicaid with Medicare and OtherInsurancea) Premiums

1) Medicare Part A and Part Bi) Qualified Medicare Beneficiary

QMBThe Medicaid agency pays MedicarePart A premiums if applicable) andPart B premiums for individuals inthe QMB group defined in Item A 2 5 ofATTACHMENT 2.2-A, through the grouppremium payment arrangement, unlessthe agency has a Buy-in agreement forsuch payment, as indicated below.Buy-In agreement for:

art A x Part Bhe Medicaid agency payspremiums, for which thebeneficiary would be liable, forenrollment in an HMOparticipating in Medicare.

TN No. 93 1.18. A~uperseaei93 005 Approval Date UN 22 gg ~f ective Date OCT 1 l g g jTN No.

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Enclosure 3 continued

Revision: HCFA-PM-97-3 af soDecember 1997State:

Citation1902 a) lO) E) ii) ii) & & qand 1905 6) of the Act Individual IODWIL

The Medicaid agency paye MedicarePart A premiums under a grouppremium payment arrangement, scbjeztto any contribution required asdescribed in ATTACHMENT 4.18-8 forindividuals in the QDWI groupdefined in item A.26 of f TTACHMENT2.2-A of this plan.

1902 a) lO) E) iii)and 1905 p) 3) A) ii)of the Act

1902 a) lo) ~) iv) 1),1905 p) 3) A) ii), and1933 of t he Act

1902 a) lO) E) iv) II),1905 p) 3 ) A ) ii) and1933 of the Act

iii) Specified Low-Income MedicareBeneficiarv LSLMB)The Medicaid agency pays MedicarePart B premiums under the sta te buy-in process for individuals in theSLMB group defined in item A.27 ofATTACHMENT 2.2-A of thie plan.

iv) Quallfvlna Individual-lmThe Medicaid agency paye MedicarePart B premiums under the State buy-in process for individuals describedin 1902 a) lO) E) iv) I) and subjectto 1933 of the Act.

v) .puallfvlna Individual-?01-2The Medicaid agency pays the portionof the amount of increase to theMedicare Part B premium attributableto the Home Health Provision to theindividuals described in 1902;a) l9)E) iv) II) and subject to 1933 of th

Act.

TN NO. 3 8 0 0 6Supereedee Approval DateTN NO. 93-005

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Enclosure 3 c o n t i n u e d

R ev i s ion : HCFA-PM-97-3 CMSO)D e c e m b e r 1997S t a t e :

C i t a t i o n1 8 4 3 b ) a nd 1 9 0 5 a )o f t h e A c t and42 CFR 431.625

1902 a ) 3 0 ) a n d1 9 0 5 a ) o f t h e A c t

v i ) O th er M edicaid R e c i ~ i e n t sThe Med ica id agency pays M ed ica r eP a r t B premiums t o make Medic areP a r t B c ov er ag e a v a i l a b l e t o t h ef o l l o w in g i n d i v i d u a l s :

A l l i n d i v i d u a l s who are: a )r e c e iv i n g b e n e f i t s u n d er t i t l e sI , IV-A, X X I V o r XV I AABDo r S SI ); b ) r e c e iv i n g S t a t esupp lemen t s unde r t i t l e XVI orc ) w i th in g a g r ou p l i s t e d a t 42CFR 43 1.6 25 d ) 2) .

n d i v i du a l s r e c e i v i n g t i t l eo r R a i l r o ad R e t ir e m en tb e n e f i t s .M e d i ca l ly n ee dy i n d i v i d u a l s

FFP i s n o t a v a i l a b l e f o r t h i sg r o u p )

2 ) O t h e r H e a l t h I n s u r a n ceT h e Medica id agency pays i n s u r an ceprem ium s f o r m ed ic a l o r a n y o t h e r t y p e o fr e m e d i a l care t o m ai nt ai n a t h i r d p a r t yr e s o u r c e f o r M e di ca id co v e re d s e r v i c e sp ro vid ed t o e l i g i b l e in d i v i d u a l s e x ce p ti n d i v i d u a l s 6 5 y e a r9 of a g e o r o l d e r a n dd i s a b l e d in d i v i du a l s , e n t i t l e d t o M e di ca reP a r t A b u t n o t e n r o l l e d i n M e di ca re P a r tB). Se e Attachment 4.22-C for methods ofdetermining cost-effectiveness.)

TN No. 98-005S u p e r s e d e s A p p r o v a l Date E f f e c t i v e DateTN NO. 96 00? I 48

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Revision: HcFA-PM-~~-~ MB)P RCH 1993State: CALIFORNIA

Citationb) ~eductibles/Coinsurance

1) Medicare Part and1902 a) 30), 1902 n),1905 a) ,and 1916 of the Act

Sections 1902a) 10) El i) and

1905 p) 3) of the Act

1902 a) 10), 1902 a) 30),and 1905 a) of the Act

42 CFR 431.625

1902 a) 10), 1902 a) 30),1905 a), and 1905 p)of the Act

Supplement 1 to ATTACHMENT 4.19-Bdescribes the methods and standards forestablishing payment rates for servicescovered under Medicare, and/or themethodology for payment of Medicaredeductible and coinsurance amounts, to theextent available for each of the followinggroups.i) Qualified Medicare BeneficiariesQMBS)

The Medicaid agency pays MedicarePart A and Part B deductible andcoinsurance amounts for QMBssubject to any nominal Medicaidcopayment) for all servicesavailable under Medicare.ii) other Medicaid Recipients

The Medicaid agency pays forMedicaid services also covered underMedicare and furnished to recipientsentitled to Medicare subject to anynominal Medicaid copayment). Forservices furnished to individualswho are described in section3.2 a) l) iv), payment is made asfollows:

For the entire range ofervices available underMedicare Part Bnly for the amount, duration,and scope of services otherwiseavailable under this plan.

iii) Dual Eligible--QMB plusThe Medicaid agency pays MedicarePart A and Part B deductible andcoinsurance amounts for all servicesavailable under Medicare and paysfor all Medicaid services furnishedto individuals eligible both as QMBsand categorically or medically needysubject to any nominal Medicaidcopayment).

T No.

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Revision: HCFA-PM-91-8 MB)October 1991 OMB No. :State/Territory: CALIFORNIA

Citation Condition or Requirement

1906 of the c) Premiums, Deductibles, CoinsuranceAct and Other Cost Sharinq ObligationsThe Medicaid agency pays allpremiums, deductibles, coinsurance andother cost sharing obligations for iteand services covered under the Stateplan subject to any nominal Medicaidcopayment) for eligible individuals inemployer-based cost-effective grouphealth plans.When coverage for eligible familymembers is not possible unlessineligible family members enroll, theMedicaid agency pays premiums forenrollment of other family members whecost-effective. In addition, theeligible individual is entitled toservices covered by the State plan whiare not included in the group healthplan. Guidelines for determining costeffectiveness are described in section4.22 h).

902 a) l o) F) d) The Medicaid agency pays premiumsof the Act for individuals described in item19 of Attachment 2.2-A.

TN No. 92 09Supercedes NOV 8 993Approval Date Effective Date JAN 3 99TN NO. 91 16 HCFA ID: 7983E

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Revis on HCFAJuly 1991

(i) O~ tio na l inimum Enrollment Period IUD to 6th Month Elieibilitv

The Medicaid agency deems thatindividuals required to enroll incost-effective employer-based grouphealth plans remain eligible forbenefits under this state plan fora minimum enrollment periodn fromthe date the individuals'enrollment becomes effective, butonly with respect to the benefitswhich are provided to theindividual as an enrollee of thegroup health plan.If so, the minimum enrollmentpericd is:

TN NO. 91-16Supersedes Approval Date OV 99 Effective Date Januarv 991TN No.