1. (a) Public Law 100-360, the Medicare Catastrophic Coverage Act of 1988, requires the Texas Department of Human Services (DHS) to pay Medicare premiums, deductibles, and coinsurance for certain clients. Effective January 1, 1989, DHS pays Medicare premiums, deductibles, and coinsurance charges for clients who:

   1. (1) are enrolled in Medicare Part A;

   2. (2) have income that is equal to or less than:

      1. (A) 85% of the federal poverty level in calendar year 1989;
      2. (B) 90% of the federal poverty level in calendar year 1990; and
      3. (C) 100% of the federal poverty level in calendar year 1991 and thereafter;
   3. (3) have resources no more than twice the limits for the SSI program.
2. (b) The client must have a Medicare card or an enrollment letter from SSA documenting entitlement to Part A. If the client has no proof of entitlement but is 65, is disabled (as determined by SSA), or has chronic renal disease, the department refers the client to SSA for enrollment. The client must enroll himself; the department is not allowed to enroll individuals for Part A as it does for Part B. The open enrollment period for Medicare is January through March, with benefits/premiums beginning in July.
3. (c) QMB clients do not receive regular Medicaid benefits. The department sends these clients a special medical care identification card that reflects QMB status.
4. (d) The department pays out-of-pocket Medicare cost-sharing expenses for QMB clients. The department does not limit deductible and coinsurance payments to services covered by the state plan.
5. (e) The size of the household depends on the number of QMBs in the household. SSI deeming policy applies. Support and maintenance policy may apply if any QMB household member is not contributing to the household's support, and the situation is not one in which the deeming policy should be considered.
6. (f) QMB eligibility begins on the first day of the month following the month the client is determined eligible for QMB benefits.
7. (g) There is no three months prior medical coverage for QMB clients.
8. (h) For QMB eligibility, the cost-of-living adjustment (COLA) in Social Security benefits is excluded for the months of January, February, and March of each year, beginning in 1991. To determine eligibility for applications and recertifications, DHS uses the pre-COLA benefit amount during those months.

Source Note:The provisions of this §358.201 adopted to be effective April 17, 1989, 14 TexReg 1083; amended to be effective May 1, 1993, 18 TexReg 1801; amended to be effective August 1, 1993, 18 TexReg 4193; amended to be effective January 1, 1991, 20 TexReg 2218; amended to be effective July 1, 1995, 20 TexReg 4275; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013.