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Medi-Cal Update 2025-1 Conditional Medicare Part A
Elimination of the Requirement to Apply for Conditional Medicare Part A
| Date | References | Clerical | Implementation |
| 02/5/25 | ACWDL 24-20, MEDIL I 25-01 | N/A | January 1, 2025 |
Background
Medicare Part A provides inpatient/hospital coverage, limited skilled nursing care, hospice, and home health care, among other types of coverage. Most Medicare members qualify for Part A without having to pay a premium but some members, who have not earned enough credits through payment of payroll taxes into the Part A trust fund, must pay a Part A premium. Those members who would be eligible for Part A by paying a monthly premium could sign up for conditional Medicare Part A which meant the member is requesting Part A only if the state will pay the premium. The Qualified Medicare Beneficiary (QMB) program helps to cover the costs of Medicare by paying the Medicare Parts A and B premiums, deductibles, and coinsurance fees.
Changes
Previous conditional Medicare Part A requirements no longer apply when applying for the QMB program.
To be eligible for the QMB program, an individual must meet the following criteria:
- Be eligible for Medicare Parts A and B,
- Be enrolled in Medicare Part B,
- Meet the net countable income requirements of below 100% of the Federal Poverty Level (FPL)
- Meet all other Medi-Cal eligibility requirements
MC applicants and members must be enrolled in Medicare Part B before they can be evaluated for the QMB program. If the individual does not already have Medicare Part A when they apply, QMB eligibility must be granted if they meet all other eligibility criteria. Following approval for QMB, The Department of Healthcare Services (DHCS) will automatically enroll them into Medicare Part A and pay the Part A premium. Through California’s Medicare Part A agreement, Medicare Part A can be established at any time of the year regardless of Medicare enrollment periods. For an individual enrolled in the QMB program, Part A enrollment and buy-in will begin the first month in which the individual’s eligibility for QMB is effective. For example, if an individual is approved for QMB in January 2025, Medicare Part A enrollment and buy-in will also begin in January 2025.
The Qualified Medicare Beneficiary (QMB) Program topic in the Medi-Cal Handbook has been updated to reflect this policy change.
Data Systems
For members approved for QMB but not yet enrolled in Medicare Part A, the first month of QMB eligibility should be entered as the Part A approval date.
Other Programs
This change only affects the Medi-Cal program.
Department of Employment & Benefits Services
Contact Person(s): Megan Turney, SSA BPIS