Qualified medicare beneficiary; medicare cost-sharing

(1)

(1)#

The term “qualified medicare beneficiary” means an individual—

(A) who is entitled to hospital insurance benefits under part A of subchapter XVIII (including an individual entitled to such benefits pursuant to an enrollment under section 1395i–2 of this title , but not including an individual entitled to such benefits only pursuant to an enrollment under section 1395i–2a of this title ) or who is enrolled under part B for the purpose of coverage of immunosuppressive drugs under section 1395 o (b) of this title,

(B) whose income (as determined under section 1382a of this title for purposes of the supplemental security income program, except as provided in paragraph (2)(D)) does not exceed an income level established by the State consistent with paragraph (2), and

(C) whose resources (as determined under section 1382b of this title for purposes of the supplemental security income program) do not exceed twice the maximum amount of resources that an individual may have and obtain benefits under that program or, effective beginning with January 1, 2010 , whose resources (as so determined) do not exceed the maximum resource level applied for the year under subparagraph (D) of section 1395w–114(a)(3) of this title (determined without regard to the life insurance policy exclusion provided under subparagraph (G) of such section) applicable to an individual or to the individual and the individual’s spouse (as the case may be).

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Qualified medicare beneficiary; medicare cost-sharing

Official source

(1)

(1)#

The term “qualified medicare beneficiary” means an individual—

(A) who is entitled to hospital insurance benefits under part A of subchapter XVIII (including an individual entitled to such benefits pursuant to an enrollment under section 1395i–2 of this title , but not including an individual entitled to such benefits only pursuant to an enrollment under section 1395i–2a of this title ) or who is enrolled under part B for the purpose of coverage of immunosuppressive drugs under section 1395 o (b) of this title,

(B) whose income (as determined under section 1382a of this title for purposes of the supplemental security income program, except as provided in paragraph (2)(D)) does not exceed an income level established by the State consistent with paragraph (2), and

(C) whose resources (as determined under section 1382b of this title for purposes of the supplemental security income program) do not exceed twice the maximum amount of resources that an individual may have and obtain benefits under that program or, effective beginning with January 1, 2010 , whose resources (as so determined) do not exceed the maximum resource level applied for the year under subparagraph (D) of section 1395w–114(a)(3) of this title (determined without regard to the life insurance policy exclusion provided under subparagraph (G) of such section) applicable to an individual or to the individual and the individual’s spouse (as the case may be).

(2)#

(A) The income level established under paragraph (1)(B) shall be at least the percent provided under subparagraph (B) (but not more than 100 percent) of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 9902(2) of this title ) applicable to a family of the size involved.

(B) Except as provided in subparagraph (C), the percent provided under this clause, with respect to eligibility for medical assistance on or after— (i) January 1, 1989 , is 85 percent, (ii) January 1, 1990 , is 90 percent, and (iii) January 1, 1991 , is 100 percent.

(C) In the case of a State which has elected treatment under section 1396a(f) of this title and which, as of January 1, 1987 , used an income standard for individuals age 65 or older which was more restrictive than the income standard established under the supplemental security income program under subchapter XVI, the percent provided under subparagraph (B), with respect to eligibility for medical assistance on or after— (i) January 1, 1989 , is 80 percent, (ii) January 1, 1990 , is 85 percent, (iii) January 1, 1991 , is 95 percent, and (iv) January 1, 1992 , is 100 percent.

(D) (i) In determining under this subsection the income of an individual who is entitled to monthly insurance benefits under subchapter II for a transition month (as defined in clause (ii)) in a year, such income shall not include any amounts attributable to an increase in the level of monthly insurance benefits payable under such subchapter which have occurred pursuant to section 415(i) of this title for benefits payable for months beginning with December of the previous year. (ii) For purposes of clause (i), the term “transition month” means each month in a year through the month following the month in which the annual revision of the official poverty line, referred to in subparagraph (A), is published.

(3)#

The term “medicare cost-sharing” means (subject to section 1396a(n)(2) of this title ) the following costs incurred with respect to a qualified medicare beneficiary, without regard to whether the costs incurred were for items and services for which medical assistance is otherwise available under the plan:

(A) (i) premiums under section 1395i–2 or 1395i–2a of this title, and (ii) premiums under section 1395r of this title , 5 5 So in original. The comma probably should be a period.

(B) Coinsurance under subchapter XVIII (including coinsurance described in section 1395e of this title ).

(C) Deductibles established under subchapter XVIII (including those described in section 1395e of this title and section 1395 l (b) of this title).

(D) The difference between the amount that is paid under section 1395 l (a) of this title and the amount that would be paid under such section if any reference to “80 percent” therein were deemed a reference to “100 percent”.

Such term also may include, at the option of a State, premiums for enrollment of a qualified medicare beneficiary with an eligible organization under section 1395mm of this title .

(4)#

Notwithstanding any other provision of this subchapter, in the case of a State (other than the 50 States and the District of Columbia)—

(A) the requirement stated in section 1396a(a)(10)(E) of this title shall be optional, and

(B) for purposes of paragraph (2), the State may substitute for the percent provided under subparagraph (B) 6 6 So in original. The words “of such paragraph” probably should follow “subparagraph (B)”. or 7 7 So in original. Probably should be “or section”. 1396a(a)(10)(E)(iii) of this title of such paragraph 6 any percent.

In the case of any State which is providing medical assistance to its residents under a waiver granted under section 1315 of this title , the Secretary shall require the State to meet the requirement of section 1396a(a)(10)(E) of this title in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this subchapter.

(5)#

(A) The Secretary shall develop and distribute to States a simplified application form for use by individuals (including both qualified medicare beneficiaries and specified low-income medicare beneficiaries) in applying for medical assistance for medicare cost-sharing under this subchapter in the States which elect to use such form. Such form shall be easily readable by applicants and uniform nationally. The Secretary shall provide for the translation of such application form into at least the 10 languages (other than English) that are most often used by individuals applying for hospital insurance benefits under section 426 or 426–1 of this title and shall make the translated forms available to the States and to the Commissioner of Social Security.

(B) In developing such form, the Secretary shall consult with beneficiary groups and the States.

(6)#

For provisions relating to outreach efforts to increase awareness of the availability of medicare cost-sharing, see section 1320b–14 of this title .

in view

Whole section

▸citations (22)

References

This rule cites 22 other rules.

42 USC § 1395iinferredUS Federal › Statutes › Title 42 › § 1395i
42 USC § 1395iinferredUS Federal › Statutes › Title 42 › § 1395i
42 USC § 1395inferredUS Federal › Statutes › Title 42 › § 1395
42 USC § 1382ainferredUS Federal › Statutes › Title 42 › § 1382a
42 USC § 1382binferredUS Federal › Statutes › Title 42 › § 1382b
42 USC § 1395winferredUS Federal › Statutes › Title 42 › § 1395w
42 USC § 9902 (2)inferredUS Federal › Statutes › Title 42 › § 9902 › (2)
42 USC § 1396a (f)inferredUS Federal › Statutes › Title 42 › § 1396a › (f)
42 USC § 415 (i)inferredUS Federal › Statutes › Title 42 › § 415 › (i)
42 USC § 1396a (n)(2)inferredUS Federal › Statutes › Title 42 › § 1396a › (n)(2)
42 USC § 1395iinferredUS Federal › Statutes › Title 42 › § 1395i
42 USC § 1395rinferredUS Federal › Statutes › Title 42 › § 1395r
42 USC § 1395einferredUS Federal › Statutes › Title 42 › § 1395e
42 USC § 1395einferredUS Federal › Statutes › Title 42 › § 1395e
42 USC § 1395inferredUS Federal › Statutes › Title 42 › § 1395
42 USC § 1395inferredUS Federal › Statutes › Title 42 › § 1395
42 USC § 1395mminferredUS Federal › Statutes › Title 42 › § 1395mm
42 USC § 1396a (a)(10)(E)inferredUS Federal › Statutes › Title 42 › § 1396a › (a)(10)(E)
42 USC § 1315inferredUS Federal › Statutes › Title 42 › § 1315
42 USC § 1396a (a)(10)(E)inferredUS Federal › Statutes › Title 42 › § 1396a › (a)(10)(E)
42 USC § 426inferredUS Federal › Statutes › Title 42 › § 426
42 USC § 1320binferredUS Federal › Statutes › Title 42 › § 1320b