MSTP Eligibility Requirements

Applicants/Recipients must meet all of the following conditions:

Eligibility for MSTP-Only

In need of dialysis or TPN and related services.
NOT eligible for regular MC due to excess property.
NOT currently eligible for Medicare if under age 65 (applies to Dialysis only).
Meets standard MC requirements for citizenship or legal immigration status, cooperation, and residency.
Meets MC linkage requirements (Dialysis only): MC linkage requirements apply.

NOTE: Undocumented individuals are NOT eligible for the Medi-Cal Special Treatment Programs.

Eligibility for MSTP - Supplement

In need of dialysis or TPN and related services.
Receives home dialysis or self-care dialysis.
Employed or self-employed AND has gross monthly earnings which exceed the Maintenance Need for one person.
Eligible under the regular MC MN or MI program with a share of cost
Meets standard MC requirements for citizenship or legal immigration status, cooperation, and residency.

NOTE: Undocumented individuals are NOT eligible for the Medi-Cal Special Treatment Programs.

Note:

If a recipient loses MSTP-ONLY eligibility because he/she becomes eligible for regular MC, eligibility for MSTP-SUPPLEMENT must be explored.

If a recipient loses MSTP-SUPPLEMENT eligibility due to excess property, eligibility for MSTP-ONLY must be explored.

Reporting Responsibilities

All MSTP clients must report any change in status that could affect their eligibility or their percentage obligation. These include, but are not limited to:

•   Loss of employment,
•   Increase/decrease in earnings,
•   Change in marital status,
•   Change in Other Health Coverage (OHC), or
•   Change in property.

Medicare Application Requirements

MSTP for Dialysis Coverage

Applicants for Dialysis coverage under MSTP-ONLY or MSTP-SUPPLEMENT must apply for and provide proof of application for Medicare within 10 days of the MC application date. Failure to provide verification, without good cause, will result in the denial of the application.

To qualify for MSTP-ONLY, a person under 65 must NOT be eligible for Medicare.

MSTP for TPN Coverage

Applicants for TPN coverage under MSTP-ONLY or MSTP-SUPPLEMENT must apply for Medicare within 60 days of the MC application. Verification of the application for Medicare is NOT required prior to approval.

Follow-Up on Medicare Applications

Social Security usually notifies a client of the outcome of his/her Medicare application within three months of the date of application. Once notified, the client must report the outcome of the application within 10 days to his/her EW.

If notification is NOT received by the end of the third month, the EW must:

Ask the client to follow-up with Social Security, OR
Inquire directly to Social Security regarding the recipient’s Medicare status via the “Referral To/From Social Security” (SC 169).

If the client is NOT eligible for Medicare, but he/she is employed or is the spouse/dependent child of an employed person, the EW must:

Ask the client to provide a “Quarters of Coverage” statement from Social Security.
Use the information to estimate when the client will become eligible for Medicare.
Enter a case alert case for the estimated date of Medicare eligibility.
Reevaluate MSTP eligibility in the month the individual is expected to become eligible for Medicare.

Note: If the client is eligible for Medicare, the EW must discontinue MSTP - ONLY for dialysis coverage, if the recipient is under 65.

Eligibility for the Medicare Dialysis Program

To be eligible for the Medicare Dialysis program, a person must be suffering from chronic kidney failure, and be:

Fully insured under Social Security (has 40 calendar quarters of covered employment), OR
Currently insured under Social Security (has 6 out of the past 13 calendar quarters of covered employment), OR
The spouse, dependent child, former spouse, widow, etc. of an insured individual.

There is a three-month waiting period between the onset of chronic kidney failure and the beginning of Medicare coverage. The entire waiting period is waived if the individual enters self-care or home dialysis training during the waiting period.