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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions
12/22/2024

12VAC30-10-310. Coordination of Medicaid with Medicare and other insurance: Premiums.

A. Medicare Part A and Part B.

1. Qualified Medicare Beneficiary (QMB).

The Medicaid agency pays Medicare Part A premiums (if applicable) and Part B premiums for individuals in the QMB group defined in subsection 25 of 12VAC30-30-10 through the group premium payment arrangement, unless the agency has a buy-in agreement for such payment, as indicated in Part B.

The Medicaid agency does not pay premiums, for which the beneficiary would be liable, for enrollment in an HMO participating in Medicare.

2. Qualified Disabled and Working Individual (QDWI). The Medicaid agency pays Medicare Part A premiums under a group premium payment arrangement for individuals in the QDWI group defined in subsection 26 of 12VAC30-30-10 of this plan.

3. Specified Low-Income Medicare Beneficiary (SLMB). The Medicaid agency pays Medicare Part B premiums under the State buy-in process for individuals in the SLMB group defined in subsection 27 of 12VAC30-30-10 of this plan.

4. Other Medicaid Recipients.

The Medicaid agency pays Medicare Part B premiums to make Medicare Part B coverage available to all individuals who are a) receiving benefits under Titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State supplements under Title XVI; or c) within a group listed at 42 CFR 431.625(d)(2).

The Medicaid agency does not pay Medicare Part B premiums for individuals receiving Title II or Railroad Retirement benefits.

The Medicaid agency does not pay Medicare Part B premiums for medically needy individuals (Federal Financial Participation is not available for this group).

B. Other Health Insurance. The Medicaid agency pays insurance premiums (through the Health Insurance Premium Payment Program (H.I.P.P.)) for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals (except those over 65 years of age and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29, VR460-01-29.1, VR460-01-29.2, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

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