Qualified Medicare Beneficiary (QMB)

People who are enrolled or are eligible to enroll in Medicare Part A may receive help with Medicare costs through the Qualified Medicare Beneficiary (QMB) program. People who meet QMB requirements may receive QMB only, or may receive QMB in addition to Medical Assistance (MA).

See Medicare for more information about eligibility criteria for Medicare. See Medicare Savings Programs for more information about eligibility for Medicare Savings Programs.

Eligibility factors and links to standard program guidelines are provided below.

Application Process.

Eligibility Begin Date.

Renewals.

Verifications.

Social Security Number.

Citizenship/Immigration Status.

Residency.

Insurance and Benefit Recovery.

Household Composition.

Eligibility Method.

Asset Guidelines.

Income Guidelines.

Deductions/Disregards.

Spenddowns.

Covered Services.

Service Delivery.

Other Requirements.

End of Eligibility Basis.

Relationship to Other Groups/Bases.

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Application Process  (standard guidelines)

Follow standard guidelines.

Process applications promptly to assure the earliest possible eligibility begin date for QMB. It is to the client’s benefit if the agency acts quickly on the application or program request.

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Eligibility Begin Date  (standard guidelines)

QMB eligibility begins the first day of the month after the month in which the county determines eligibility. Eligibility is not possible before or for the month of application.

l  QMB-eligibles may qualify for the Service Limited Medicare Beneficiary (SLMB) program for payment of Medicare Part B premiums for up to three months before the month of application and during the processing months.

Example:

Myrtle applies for QMB on March 10. Her income is under 100% FPG and assets are within the $10,000 limit for a household of one. The earliest QMB can be opened is April 1.

Action:

Approve Myrtle for SLMB effective December 1 (three months before the application month). Change Myrtle’s coverage from SLMB to QMB effective April 1.

l  People who are eligible for QMB may only receive SLMB during retroactive or processing months as described above. Determine eligibility for:

n  SLMB for retro months.

n  SLMB for the month that eligibility is approved.

n  QMB for future months.

Example:

Melba’s income and assets are within QMB limits. She requests SLMB benefits on an ongoing basis so only her Part B premium will be paid. She does not want QMB to cover Medicare co-payments and deductibles.

Action:

Because she is eligible for QMB, Melba cannot receive SLMB on an ongoing basis.

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Renewals  (standard guidelines)

Do not require six-month renewals for QMB enrollees who meet any of the exceptions noted in six-month renewals.

Verifications  (standard guidelines)

Verify enrollment or eligibility to enroll in Medicare Part A.

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Social Security Number  (standard guidelines)

Follow standard MA guidelines.

Citizenship/Immigration Status  (standard guidelines)

U.S. citizens who are enrolled or eligible to enroll in Medicare are exempt from the requirement to provide citizenship or identity documentation.

For noncitizens, follow standard guidelines for federally funded MA.

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Residency  (standard guidelines)

Follow standard MA guidelines.

Insurance and Benefit Recovery  (standard guidelines)

Medicare Part A premiums for QMB-eligible clients are considered cost effective by the Benefit Recovery Section (BRS) A section of DHS which pursues collection of third party payments and determines if health insurance is cost-effective. and do not require further review.

DHS pays Medicare premiums through the Medicare buy-in for people who are enrolled in QMB.

Note:  People who are age 65 or older who are not currently enrolled in Medicare and receive only Supplemental Security Income (SSI) A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind or disabled. benefits must be referred to Medicare to enroll in available coverage as a condition of their MA eligibility. Do not enroll the person in QMB until Medicare eligibility has been established.

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Household Composition  (standard guidelines)

Follow standard MA guidelines to determine household size for QMB eligibility even if a household size of one is used for MA for Employed Persons with Disabilities (MA-EPD), the TEFRA option, or a waiver program for people with disabilities (CAC, CADI, DD or BI).

Example:

Chris applied for QMB and MA with the CADI waiver. He lives with his wife, Joan, and their four children.  

Action:

Use a household size of six for QMB. For MA/CADI use a household size of one.

Always use a household size of one to determine QMB eligibility for a person who is eligible for the Elderly Waiver (EW).

Example:

Sue applies for EW and is eligible for Medicare. She lives with her husband Greg.  

Action:

Determine Sue’s eligibility for both EW and QMB using a household size of one.

Follow standard MA guidelines in Determining Household Size for MA to determine which household members to count in the household size when determining the QMB eligibility for a person who is not requesting EW, but has a spouse who is on EW. However, do not count the person’s spouse in the household size if the spouse is on EW. See Exceptions to MA Household Size.

Example:

Jack is on EW and is eligible for Medicare. He lives with his wife, Wendy, and their 17-year-old daughter Mary. Wendy is eligible for Medicare and is not requesting EW.

Action:

Determine Jack’s eligibility for both EW and QMB using a household size of one. Determine Wendy’s eligibility for QMB using a household size of two (Wendy and Mary).

Eligibility Method  (standard guidelines)

Use Method B for income and assets.

Note:  If people who are also eligible for MA meet more than one basis of eligibility, they may choose the most advantageous basis for MA, but must use a Method B basis for the Medicare Savings Program.

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Asset Guidelines  (standard guidelines)

Asset limit is:

l  $10,000 for a household of one.

l  $18,000 for a household of two or more.

Income Guidelines  (standard guidelines)

Income standard is 100% FPG. Income eligibility is determined on a monthly basis. QMB does not have a six-month or annual standard.

Example:  

Melba is paid bi-weekly through her employer. In December, she will receive three paychecks making her income higher than the 100% FPG standard. She is not eligible for QMB in December.

Action:

Melba’s total net income exceeds the QMB standard in December but her total net income is under the SLMB standard. Change programs from QMB to SLMB for December. Re-open QMB for January.

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Deductions/Disregards  (standard guidelines)

In addition to allowing the income deductions and disregards for the applicable age 65 or older, blind, or disabled basis, apply the standard $20 disregard when determining QMB eligibility. Do not allow the standard $20 disregard for MA.

Disregard RSDI cost-of-living adjustments (COLA) for January through June of each year.

When calculating income, exclude Aid and Attendance benefits and Allowances for Unusual Medical Expenses received from the Veteran’s Administration.

When a person is in a long-term care facility (LTCF), use a long-term care budget to determine their MA eligibility and a Medicare Savings Program budget to determine QMB eligibility.

Spenddowns  (standard guidelines)

There are no spenddown provisions for QMB. People with income in excess of the standard are not eligible.

Example:

Bud’s income is 125% FPG. He is ineligible for QMB even if he has covered expenses that would allow him to spend down to 100% FPG.

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Covered Services  (Prepaid MHCP Manual)

The benefits of the QMB program are:

l  Payment of Medicare Part A and Part B premiums.

l  Payment of Medicare cost-sharing (co-payments A fixed amount a person is required to pay for each episode of a particular treatment, medical supply, or equipment. For example, a policy might require a $5 co-payment for each prescription while the insurance pays the remainder. and deductibles The amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance policy. For example, if an insured person has a $1000 deductible, he or she must incur $1000 in medical costs before the policy begins paying benefits.) for Medicare services provided by Medicare-eligible providers.

Service Delivery  (Prepaid MHCP Manual)

People who are only receiving QMB assistance are excluded from managed care enrollment.

Other Requirements

Enter an LTCF living arrangement on the STAT/FACI screen in MAXIS and on the RLVA screen in MMIS for someone in an LTCF who is open on QMB only.

End of Eligibility Basis

Eligibility for QMB ends if the enrollee is no longer Medicare-eligible, or has excess income or assets.

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Relationship to Other Groups/Bases  (standard guidelines)

See Medicare Savings Programs for general information about the relationship between MSPs and other program eligibility.

It is rarely advantageous for people in LTC to be QMB-only because:

l  Medicare Part A covers very limited skilled nursing care.

l  Payment may not be confirmed until several months after the care is received.

However, if you know Medicare Part A is covering any of the LTCF costs, it is advantageous for people to be QMB-only because there wouldn't be an LTC spenddown.

Note:  If Medicare retroactively covers any of the LTCF costs of people who are open on both QMB and MA while in an LTCF, the LTCF must reimburse the person for any amounts overpaid to the facility.

People may qualify for MA and QMB concurrently.

l  People with incomes at or under 100% FPG qualify for QMB, and also for MA without a spenddown if their assets are within MA limits.

l  Because QMB allows a standard $20 income disregard and MA does not, people with incomes over 100% FPG but no more than 100% FPG + $20 are within the QMB income limit but must meet a spenddown to qualify for MA.

l  People with incomes at or under 100% FPG, but assets between the MA and the QMB limits, qualify for QMB only.

Example:

Clara has countable assets of $2,000. Her income is within QMB limits after deducting $20 but exceeds MA limits since the $20 is not allowed.

Action:

Clara qualifies for QMB but must spend down to 75% FPG to qualify for MA.

Example:

Blanche has countable assets of $8,000. Her income is within QMB limits. She does not wish to reduce her assets to qualify for MA.

Action:

Because Blanche’s assets are within the QMB limit but not the MA limit, approve her for QMB only.

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