The SLMB+ Medicare savings program has higher income limits but is only available to those not enrolled in a full-benefit Medicaid program, such as MAPP. In this case, the petitioner was initially enrolled in MAPP and therefore not enrolled in SLMB+. After telling the agency he preferred to be in SLMB+ on October 29, the agency switched his enrollment effective December 1. ALJ Wendy I. Smith concluded this was appropriate, since the agency had to give timely notice of the MAPP disenrollment.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on December 19, 2024, under Wis. Stat. § 49.45(5), and Wis. Admin. Code HA § 3.03(1), to review a decision by the Fond Du Lac County Department of Social Services regarding Medical Assistance (MA), a hearing was held on January 22, 2025, by telephone. The hearing was held with a companion appeal (FOO-216453). A separate decision will be issued on that companion appeal.
The issue for determination is whether the agency correctly enrolled Petitioner in the Medicare Savings Program with an effective date of December 1, 2024.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Gena Miller
Fond Du Lac County Department of Social Services
50 N Portland St
Fond Du Lac, WI 54935
ADMINISTRATIVE LAW JUDGE:
Wendy I. Smith
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Fond Du Lac County and a recipient of Medical Assistance (MA) in the Medicaid Purchase Plan (MAPP) program since February 2024.
- In a notice dated October 24, 2024, Petitioner was found eligible for FoodShare benefits. In the same notice, Petitioner was advised that his MAPP enrollment would continue, but that he was ineligible for enrollment in the Medicaid Savings Program (MSP), Specified Low-Income Medicare Beneficiary Plus (SLMB+), because he was currently enrolled in MAPP and could not be enrolled in both programs.
- On or about October 28, 2024, Petitioner contacted the agency to explain that he preferred to be in the MSP program instead of MAPP.
- In a notice dated October 29, 2024, Petitioner was advised that he was eligible for enrollment in the MSP SLMB+ program as of December 1, 2024. Per his request, his MAPP enrollment would end as of December 1, 2024.
- Petitioner receives $1,519.18 per month in the form of Social Security benefits and pension/retirement benefits.
- Petitioner now appeals to the Division of Hearings and Appeals.
Discussion
Medicare is a health insurance program administered by the federal Centers for Medicare & Medicaid Services (CMS) for people aged 65 and older and other people with qualifying disabilities or health conditions. Medicare is divided into two primary types of insurance coverage. Hospital insurance (Part A) pays for hospitalization and certain skilled nursing facility expenses. Medical insurance (Part B) pays for physician services and certain other expenses. Wisconsin Medicaid Eligibility Handbook (Medicaid Handbook) § 32.1.1.
Medicare beneficiaries may be responsible for out-of-pocket cost-sharing charges through monthly premiums, deductibles, and coinsurance payments. Wisconsin Medicaid administers the following Medicare Savings Programs (MSP) that pay some or all of an eligible Medicare beneficiary’s cost-sharing charges:
- Qualified Medicare Beneficiary (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Specified Low-Income Medicare Beneficiary Plus (SLMB+)
- Qualified Disabled and Working Individual (QDWI)
Id. Each of these programs has varying benefits, as well as financial and non-financial eligibility requirements. The QMB income limit is 100% of the federal poverty level (FPL) (currently $1,255.00 per month for a single-person assistance group). Id. at §§ 32.2.3, 39.5. The SLMB income limit is at least 100% FPL but less than 120% FPL (or $1,506.00 per month). Id. at §§ 32.3.2, 39.5. The SLMB+ income limit is at least 120% FPL but less than 135% FPL (or $1,694.25 per month). Id. at §§ 32.4.2, 39.5. The QDWI income limit is 200% FPL (or $2,510.00 per month). Id. at §§ 32.5.2, 39.5.
In this matter, Petitioner is financially eligible for the MSP SLMB+ subprogram based on his Social Security and retirement/pension income in the amount of $1,519.18 per month. However, program rules for SLMB+ state that to be eligible, the member may not be also enrolled in a full-benefit Medicaid program. Id. at § 32.4.1. A person with an unmet deductible should not be considered ineligible for Medicaid until they meet the deductible. Id.
Petitioner has been enrolled in MAPP, a full-benefit Medicaid program, since February 2024. Per the rules above, Petitioner could not be concurrently enrolled in MSP SLMB+. At the hearing, Petitioner testified to confirm that he no longer needs MAPP and contacted the agency on October 28, 2024, to request enrollment in MSP to help with his Medicare premium. The agency processed that request to enroll him in MSP SLMB+ as of December 1, 2024, and disenrolled him from MAPP in accordance with program rules. As for the effective date of his MSP enrollment, the agency processed his request on October 29, 2024, but the agency’s actions do not go into immediate effect. The agency determines an eligibility effective date to allow for timely notice of termination of the MAPP benefits, in accordance with Medicaid Handbook Section 23.1.4.2. Based on the record, an effective date of December 1, 2024, was appropriate.
Conclusions of Law
The agency correctly enrolled Petitioner in the Medicare Savings Program with an effective date of December 1, 2024.
THEREFORE, it is
Ordered
That Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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