MaineCare Eligibility
Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities-the Medicare Savings Program (MSP)

Contents

Contents of this page
6.1 Medicare Savings Program (MSP): What is it?
6.2 Medicare Savings Program (MSP) eligibility
6.3 How to apply to the Medicare Savings Program (MSP)
6.4 Does the Estate Recovery Program try to recoup benefits from the Medicare Savings Program (MSP)?
6.5 The appeals process for the Medicare Savings Program (MSP)
6.6 Medicare Savings Program (MSP) resources

Section 6: Help with Medicare Costs: The Medicare Savings Program

6.1 Medicare Savings Program (MSP): What is it?

Medicare doesn’t pay the full cost of health care, including deductibles, co-pays, co-insurance and premiums. MaineCare has a benefit that will help pay these costs, the Medicare Savings Program – which includes Qualified Medicare Beneficiaries (QMB); Specified Low-Income Medicare Beneficiaries (SLMB) and Qualified Individuals (QI). These benefits are sometimes called the buy-in or dual eligible benefits.

For an overview of the program, go to our page: Help with Medicare Costs: The Medicare Savings Program.

Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.2 Medicare Savings Program (MSP) eligibility

In order to get the MSP benefit, you now need to meet just two criteria:

• You must be enrolled in Medicare and have Medicare Part A coverage.
• Your "countable" income, after subtracting all the allowable disregards, must be at or below 185% FPL.

Allowable deductions (deductions must be made in order listed below)

1. Federal disregard: deduct $20 from an individual’s or couple’s gross income (unless the only income received is from a need-based source, like a Veteran's pension, or all in-kind donations).
2. Impairment-related work expenses (this deduction is only for disabled individuals/couples who are age 64 or younger and working): deduct impairment-related work expenses from an individual’s or couple’s gross income.
3. Earned income disregard (this deduction is only for people who are earning wages through employment):
   

   a. Deduct $65 from an individual’s or couple’s earned income.
   b. Deduct half of the remaining amount of earned income.

4. State disregard: deduct $55 from an individual’s gross income, or $80 from a couple’s gross income.
5. Other less common disregards (for example, for dependent children or for a couple where only one spouse is applying for MaineCare). Contact Maine Equal Justice for more information.

Because not everyone will receive the same disregards, it is difficult to give one number that represents an upper limit for income eligibility. However, in general, for people who are not working, if their income is at or below the following amounts, they will be eligible for MSP:

If single:

• $1,745 (this is $75 over 185% FPL).

If married:

• $2,347 (this is $100 over 185% FPL). If only one of you wants to enroll in MSP, your joint gross income can be up to $319 higher, which is $2,666.

Remember the earned income disregard! If you are working, your income can be even higher.

The Medicare Savings Program (MSP) has three components. The component you are eligible for depends on your countable income (after taking the deductions above):

• If you are enrolled in Medicare and your countable income is at or below 150% of the federal poverty level (FPL), you are eligible for the Qualified Medicare Beneficiaries (QMB—often called “Quimby”) portion of the MSP benefit.
• If you are enrolled in Medicare and your countable income is over 150% and equal to or less than 170% FPL, you are eligible for the Specified Low-Income Medicare Beneficiaries (SLMB—often called “Slimby”) portion of the MSP benefit.
• If you are enrolled in Medicare and your countable income is over 170% and equal to or less than 185% FPL, you are eligible for the Qualified Individual (QI) portion of the MSP benefit.

Even if you aren’t sure you are eligible, it’s a good idea to apply!

Important: When determining income eligibility, be sure to note whether you are using amounts that represent countable income (after disregards), or amounts that represent gross income (before disregards).

Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.3 How to apply to the Medicare Savings Program (MSP)

You can enroll in the Medicare Savings Program (MSP) by applying to the Maine Department of Health and Human Services (DHHS), either through the DHHS regional offices or by calling 1-877-543-7669.

People are enrolled in MSP for 12 months at a time. Before the end of the 12-month enrollment period, DHHS will send you a review form. You must return the form and continue to meet applicable eligibility guidelines for continued enrollment.

Important: Most people who are found eligible for MSP will be automatically enrolled in the Low Cost Drugs for the Elderly and Disabled (DEL) benefit (and most people enrolled in DEL will be automatically enrolled in MSP). For more information about DEL, see our "Who's Covered?" chart.

MSP coverage begins the second month following your application (for instance, if you apply any time in February, you would receive coverage starting on April 1). Enrollment in the SLMB or QI portion of the MSP may be retroactive up to 3 months before the date of your application, if you were eligible during that time period.

Like all other MaineCare programs, DHHS must make an eligibility decision within 45 calendar days (or else they must temporarily provide the benefit until they are able to make a final decision). Temporary coverage after the 45th day will not happen automatically - you would need to call DHHS and note that your application has been pending for 45 days.

Because it is the Social Security Administration (SSA) that collects the Part B premiums, even if DHHS makes a decision on your MSP application within 45 days, it may be several months until SSA stops taking your Part B premium out of your Social Security retirement or Social Security Disability Insurance (SSDI) check. You will receive a lump sum check from SSA to reimburse you for any Part B premiums that were taken out of your benefit check when in fact your MSP benefit has been paying that premium.

Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.4 Does the Estate Recovery Program try to recoup benefits from the Medicare Savings Program (MSP)?

The MaineCare Estate Recovery Program does not apply to the Medicare Savings Program (MSP), unless you have also received full-benefit MaineCare.

Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.5 The appeals process for the Medicare Savings Program (MSP)

Each applicant for or member of the Medicare Savings Program (also for the Low Cost Drugs for the Elderly and Disabled [DEL] benefit, or Maine Rx Plus) has the right to appeal almost any Department of Health and Human Services (DHHS) decision that adversely affects eligibility or benefits. The MSP provides significant financial assistance with Part D benefits and covers the Part B premium (and for some, all of the Part A and B costs); therefore, it is of crucial importance to get or maintain membership in the MSP for all those who are eligible.

Members and applicants have the right to assistance with an appeal from an attorney, a family member, or another trusted person. Help may also be available through Pine Tree Legal Assistance or Legal Services for the Elderly (toll-free 1-800-750-5353; in the Augusta area, call 623-1797).

Appeals must be made within 30 calendar days of the date of the DHHS written decision to deny or terminate MSP. To appeal a MSP decision, call or write to the regional DHHS office and ask for a fair hearing.

If appealing a DHHS decision to end MSP benefits, the coverage can continue up to the time of the fair hearing decision, but only if the request for a fair hearing is made within 12 calendar days of the date on the DHHS decision. If the 12-day deadline is missed, an appeal within the 30-day deadline can still be filed; however, the coverage will not continue up to the hearing decision. If the person wins the hearing, then DHHS may have to pay any back bills.

Section 6: Additional MaineCare Benefit for Seniors and Adults with Disabilities - the Medicare Savings Program (MSP)

6.6 Medicare Savings Program (MSP) resources

DHHS Pharmacy Help Desk: 1-866-796-2463 (TTY 207-287-1828)

Maine Equal Justice: 1-866-626-7059

Legal Services for the Elderly (LSE) HelpLine: 1-800-750-5353

Pine Tree Legal Assistance (PTLA) (for appeals)

Consumers for Affordable Health Care HelpLine: 1-800-965-7476
The Maine Department of Health and Human Services: 1-877-543-7669
Maine Equal Justice Partners: 1-866-626-7059

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