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Effective: December 1, 2006 |
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03.35.05ar1 - Qualified Medicare Beneficiary (QMB) (Archive) |
Archived: May 1, 2007 |
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 in addition to Medical Assistance (MA).
Medicare-eligible people are age 65 or older, blind or disabled. Some disabled people who no longer receive a cash benefit from the Social Security Administration (SSA) due to work but remain medically disabled have extended Medicare coverage and are potentially eligible for QMB. See Medicare Savings Programs for more information on these situations.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Determine eligibility for QMB promptly. See eligibility begin date below.
Eligibility begins the first day of the month after the month in which the county agency makes an eligibility determination. Eligibility is not possible before or for the month of application.
l QMB-eligibles may be eligible 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 until the first month of QMB eligibility.
l People who are eligible for QMB may not choose to receive SLMB instead of QMB. After receiving SLMB for any retro months through the month of the eligibility determination, they must receive QMB instead.
Example:
Melba’s income and assets are within QMB limits. She requests to receive only SLMB benefits on an ongoing basis because she only wants payment of her Part B premium and does not wish to receive any other QMB benefits.
Action:
Because she is eligible for QMB, Melba cannot choose SLMB. Advise her that she does not need to use her QMB for Medicare co- payments and deductibles if she does not wish to.
Renewals (standard guidelines)
Do not require six-month renewals for QMB enrollees who meet any of the exceptions noted in six-month renewals.
Verify enrollment in Medicare Part A when required for QMB eligibility.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard guidelines for federally funded MA.
Residency (standard guidelines)
Follow standard MA guidelines.
Medicare Part A premiums for QMB-eligible clients are considered cost-effective by BRS and do not require further review.
DHS pays Medicare premiums through the buy-in for people who are enrolled in QMB.
Note: People who are age 65 or older and receive only Supplemental Security Income (SSI) benefits should be referred to Medicare for voluntary enrollment in Parts A and B, and then enrolled in QMB.
Household Composition (standard guidelines)
Follow standard MA guidelines. This includes people who are eligible for MA for Employed Persons with Disabilities (MA-EPD), the TEFRA option, or a waiver program (CAC, CADI, MR/RC, or TBI) in addition to QMB.
Exception: Use a household size of one to determine QMB eligibility for people who are eligible for the Elderly Waiver (EW) and for the non-EW spouse.
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.
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 standard is 100% FPG.
Deductions/Disregards (standard guidelines)
In addition to allowing the income deductions and disregards for the applicable age 65 or older, blind, or disabled status, 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.
Deduct allocations for the needs of relatives of a long-term care (LTC) client from income when determining QMB eligibility for the LTC client.
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.
Covered Services (standard guidelines)
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 and deductibles) for Medicare services provided by Medicare-eligible providers.
People who are eligible for only QMB are excluded from managed care enrollment.
Do not use a long-term care (LTC) spenddown for people who are open as QMB-only in an LTCF. However, you must enter a Long-Term Care Facility (LTCF) living arrangement on the STAT/FACI screen in MAXIS and on the RLVA screen in MMIS.
Eligibility for QMB ends if the enrollee is no longer Medicare-eligible, or has excess income or assets.
Relationship to Other Groups/Bases (standard guidelines)
People residing in Institutions for Mental Diseases (IMDs) are not eligible for QMB unless they meet one of the conditions that allow MA eligibility in an IMD. People who would be eligible for QMB if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost-effective coverage. See Medicare premiums.
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 can receive Alternative Care (AC) and QMB at the same time.
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.