Equitable relief for people with Medicare and Marketplace coverage

Individuals who have Medicare Part A coverage are considered to meet minimum coverage requirements under the Affordable Care Act and are therefore ineligible to receive premium and cost-sharing assistance for Marketplace health insurance plans.  Individuals who have Medicare Part B coverage are eligible to receive premium and cost-sharing assistance for Marketplace health insurance plans.  The Social Security Administration states that individuals may not have known they were not eligible for premium and cost-sharing assistance for Marketplace health insurance plans if they had Medicare Part A coverage.  This may have caused individuals to not enroll in Medicare Part B, drop Part B or enroll late in Part B and be assessed a penalty.

The Social Security Administration allows individuals to request equitable relief from their failure to have Medicare Part B.  The Social Security Administration is phasing out this relief but has extended it until June 30, 2020.

To be eligible for equitable relief, individuals must have enrollment in premium-free Medicare Part A and meets one or more of the following: Part A entitlement date between July 2013 and June 2020; notified of retroactive Part A entitlement between October 1, 2013 and June 30, 2020 or special enrollment period ended between October 1, 2013 and June 30, 2020.  The beneficiary must also request Part B enrollment or premium surcharge rollback or removal, mention equitable relief or being enrolled in both a Marketplace plan Medicare Part A, and present proof of Marketplace enrollment for any period between January, 2014 and June 30, 2020.  (EM-16033 REV 7, October 25, 2019.)

Updated Specialty Thresholds for Medi-Cal Programs in 2018-2019

Effective July 1, 2018, through June 30, 2019, the FMBA amount for a family member living with the community spouse of an institutionalized spouse is $2,058 (compared to last year’s $2,030). DHCS ACWDL 18-13 (July 3, 2018); DHCS ACWDL 18-13E (November 20, 2018).

As a result of the 2.8% COLA for 2019 Social Security benefits, DHCS has updated various threshold documents, including Pickle and SSI/SSP payment levels. This change does not affect MAGI eligibility. DHCS ACWDL 18-27 (December 7, 2018).

Effective January 1, 2019, the community spouse resource allowance is $126,420.  The maximum spousal income allocation/minimum monthly maintenance needs allowance is $3,161. DHCS ACWDL 18-28 (January 14, 2019).

Medi-Cal System Treatment of New Medicare Beneficiary Identifiers

The Centers for Medicare and Medicaid Services (CMS) is planning to phase in Medicare Beneficiary Identifiers (MBIs) between April 2018 and April 2019 to replace the current Medicare Health Insurance Claim Number (HICN) based on beneficiary Social Security Numbers.  The MBI and HICN will be linked and used, with SSA generating HICNs and CMS generating MBIs.

Starting April 2018, the SAWS and MEDS systems, along with other statewide systems, are expected to be able to receive MBI information.  The transition period will run through December 2019.  During this time, when beneficiaries will only receive an MBI, Counties are not to share MBI with anyone.  County workers will continue to enter Medicare information as they receive it.  A new field for MBI has been added to MEDS.

DHCS MEDIL I 17-15 (September 18, 2017).

Updates to Medi-Cal Aged and Disabled, Medicare Savings Program Thresholds

DHCS has updated the thresholds for the the Medi-Cal Aged and Disabled Federal Poverty Level program.  As of April 1, 2017, the monthly income limit for an individual is $1235 ($1005 + $230 disregard); the monthly income limit for a couple is $1664 ($1354 + $310 disregard).

DHCS ACWDL 17-19 (June 23, 2017)

Effective January 1, 2017, allocations, property limits, and premium amounts have been updated:

  • The SSI Standard Allocation is $368.
  • The SSI Parental Allocation is $735 for an individual (if one ineligible parent lives with a child), or $1103 for a couple (if both ineligible parents live with a child).
  • The Medicare Part A premium is $413 for those not receiving free Part A.  A beneficiary with 30-39 quarters has a reduced premium of $227.
  • The Medicare Part B premium is $109 on average for those held harmless, while it is $134 for those who are new to Medicare or not subject to hold harmless status.  The Part B deductible is $183.
  • The property limits for Medicare Savings Programs are $7390 for an individual and $11,090 for a couple.

DHCS ACWDL 17-20 (June 30, 2017).

DHCS 2017 FPL Charts

DHCS has updated its annual eligibility charts to reflect the 2017 federal poverty level ceilings for Medi-Cal and other health programs.  The new FPLS are effective 1/1/17 for MAGI programs, 1/1/17 for MSP applicants and recipients without Title II income, 3/1/17 for MSP applicants and recipients with Title II income, and 4/1/17 for ABD FPL programs.

Note that the new monthly ABD FPL thresholds will be $1235 for an individual and $1663 for a couple.

DHCS ACWDL 17-10 (March 3, 2017).

Transitioning from MAGI Medi-Cal to Medicare

As of 8/1/16, CalHEERS has been able to verify Part A entitlement through the Federal Data Hub.  Medicare entitlement precludes MAGI New Adult group eligibility, though it does not preclude eligibility through the MAGI Parent/Caretaker Relative or pregnancy coverage groups when eligible.

New Medi-Cal applicants who are eligible for Medicare will be evaluated for Non-MAGI Medi-Cal programs.  For New Adult MAGI beneficiaries who are become eligible for Medicare, the county shall evaluate for other MAGI programs.  Beneficiaries shall be placed on a Soft Pause until a Non-MAGI Medi-Cal eligibility determination can be made.

DHCS ACWDL 17-08 (February 24, 2017).