Section 140.331. Benefit coverage

(a) The Department will provide the following under the Healthy Horizons Categorically Needy Program:

(1) Full categorically needy benefits.

(2) Qualified Medicare beneficiaries are also eligible for the following:

(i) Buy-in of the Medicare Part A premium if the individual is enrolled in Medicare Part A and paying the Part A premium.

(ii) Buy-in of the Medicare Part B premium.

(iii) Payment of the Medicare Part A and Part B deductibles and coinsurances. The combined Medicare and Medicaid payment will not exceed the Department’s Medicaid fee for the service provided.

(b) The Department will provide the following under the QMB Healthy Horizons Medicare Cost-Sharing Program:

(1) Buy-in of the Medicare Part A premium if the individual is enrolled in Medicare Part A and paying the Part A premium.

(2) Buy-in of the Medicare Part B premium.

(3) Payment of the Medicare Part A and Part B deductibles and coinsurances. The combined Medicare and Medicaid payment will not exceed the Department’s Medicaid fee for the services provided.

(c) Under the Healthy Horizons SLMB Medicare Cost-Sharing Program, the Department will provide buy-in of only the Medicare Part B premium if the individual is enrolled in or eligible for Medicare Part A.

(d) For QI-1s, to the extent that Federal funding is provided, the Department will provide full Medicaid payment of the Medicare Part B Premium if the individual is enrolled in or eliglble for Medicare Part A.

(e) For QI-2s, to the extent that Federal funding is provided, the Department will provide partial Medicaid payment of the Medicare Part B Premium if the individual is enrolled in or eligible for Medicare Part A. This is a reimbursement to the recipient, not a premium payment to Medicare.

(f) For QI-2s, partial payments of Medicare Part B premium payment will be made for the calendar year. For all other recipients of payments, the Department will pay the Medicare Part A premium, if appropriate, and the Medicare Part B premium beginning with the month following the month in which the applicant is determined eligible.

The provisions of this § 140.331 amended May 24, 1996, effective May 25, 1996, and apply retroactively to January 1, 1993, for the SLMB Medicare Cost-Sharing Program for persons whose income does not exceed 110% of the FPIGs, and retroactively to January 1, 1995, for persons whose income does not exceed 120% of the FPIGs, 26 Pa.B. 2412; amended December 30, 1999, effective January 1, 2000, 30 Pa.B. 15. Immediately preceding text appears at serial pages (216201) to (216202).

Notation

Authority

The provisions of this § 140.331 amended under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. § § 201(2) and 403(b)).