2670 Restricted Coverage for Medicare Beneficiaries (QMB/LMB/QWD) - The Qualified Medicare Beneficiary (QMB), Low Income Medicare Beneficiary (LMB), and Qualified Working Disabled (QWD) programs provide for coverage of Medicare premiums and/or cost sharing requirements based on the criteria established below.
2671 Qualified Medicare Beneficiaries (QMB) - Persons who are entitled to Medicare benefits under Part A (including those entitled by reason of enrollment in the premium-paying Part A program) shall be eligible for restricted medical assistance without a spenddown if:
In addition to the above criteria, the individual must meet the general eligibility requirements of 2100. The individual does not have to be determined disabled to receive QMB coverage.
2671.1 Effective Date of QMB Eligibility - If approved for QMB, coverage becomes effective with the month following the month in which action on the individual’s case is taken. Thus, there is no eligibility for medical benefits under the QMB program prior to this month. If there is a break in assistance of one or more months, eligibility for QMB can only be reestablished in the month following the month of action. The following exceptions apply:
2671.2 Medicare Part A Eligibility - As mentioned above, those persons who are entitled to Medicare Part A coverage would be potentially eligible for QMB. Most persons who are entitled to SSA or Railroad Retirement benefits through their own account or through a spouse's or parent's account and who are age 65 or older or disabled for 24 months will automatically receive Part A coverage. There are some groups who although eligible for Part A must formally apply for coverage. This includes persons with end-stage renal disease and certain disabled widows and widowers. It also includes former federal, state, and local government employees whose employment became subject to the Medicare tax.
Persons who are entitled to Medicare Part A by paying a premium include only those who do not have sufficient work history to qualify for coverage and who are 65 or older. Thus, for example, persons who receive SSI aged benefits only would qualify for QMB while those receiving SSI disability benefits only would not.
A person must enroll in and be receiving Part A benefits in order to be eligible for QMB coverage. QMB eligibility can begin no earlier than the first month of Part A coverage. For persons claiming Part A recipient status, a copy of their card or other documentation from SSA must be obtained. For those persons not currently receiving Part A, proof of their enrollment and beginning month of coverage will be required.
Persons who qualify for QMB will not be automatically enrolled and bought in to the Part A program as they would be for Part B. If they want Part A coverage, they would need to enroll for it on their own at the local SSA office. There is a 7-month initial enrollment period which begins in the third month prior to the month the person turns age 65. Part A coverage would begin either in the month the person turns 65 or in a following month depending on when enrollment occurs. If this initial period has passed, the person can generally only enroll during a general enrollment period which is limited to the months of January through March. Part A coverage would not begin until July 1 in these instances. There is also a special enrollment period connected with the premium Part A program for persons who did not enroll at their first opportunity because they were covered under an employer group health program. If that coverage ends, they have a 7-month period from the month the coverage ends to enroll for Part A.
QMB eligibility is to be determined on all Part A recipients who request medical assistance. Those who are not currently receiving Part A coverage but who appear to be eligible for Part A and who request QMB coverage may have QMB status initially determined if they apply within a designated enrollment time period (i.e., during January, February, and March or during an initial enrollment period). They would need to enroll for Part A at the SSA office. If proof of conditional enrollment is provided, QMB eligibility would begin in the month of July if otherwise eligible. If the person applies for QMB outside of the permitted enrollment period, QMB eligibility would have to be denied until such time that the person can enroll for and begin receiving Part A benefits.
It is not mandatory for a person to enroll for Part A coverage in order to be eligible for medical assistance. If they want QMB coverage, they will need to do so.
2671.3 Income and Resource Methodologies - The income and resource methodologies of the MS program shall be applicable in determining eligibility with the exception of the 6 month base period rule and the allowable resource standards. Only the needs, income and resources of the individual and his or her spouse or parent(s) shall be considered.
Countable income shall be determined using the independent living disregards as specified in 7240. This would also apply to persons in LTC living arrangements. Only that person's income would be considered including the amount of any income the person is allocating to a community spouse or other family members in accordance with 8243 (4) or 8244.2. This allocation would not be deducted in determining countable income for QMB purposes. However, if an individual applies for QMB status who is receiving such allocation, the amount of that allowance must be considered in determining this person's eligibility.
Beginning January 1 of each year, the amount of any cost-of-living increase in Social Security benefits provided for that year shall be disregarded in determining QMB eligibility both for applicants and recipients until the new federal poverty level standards are put into effect.
The general resource guidelines of 5200 shall be applicable in determining countable resources. A transfer of resources under the spousal impoverishment provisions of 8144 and subsections would not be recognized in the QMB determination until the resource has been formally transferred.
A one-month base period shall be applicable to QMB determinations in accordance with 7330 (1). Total countable income to be considered in the eligibility base period shall be compared against the appropriate monthly standard (see Appendix, Item F-8). Eligibility exists if the countable income does not exceed this level and resources are within allowable levels.
Eligibility for QMB coverage shall be determined separately for the qualifying individual except in instances in which there is more than one qualifying person in the family group.
In such instances, a single determination for all qualifying persons would be applicable. If the qualifying individual is a legally responsible person and the remaining family members request assistance (e.g., MA), his or her needs, income, and resources would also be included in that eligibility determination.
If the person's countable income exceeds the poverty level standard, there is no eligibility for QMB coverage. Persons who are not eligible for QMB may, however, be able to qualify for regular medical benefits based on a cash or spenddown determination.
2671.4 Eligibility Determination - Eligibility for QMB coverage can be established in any medical program. However, only the MS and SI programs offer a formal determination as part of the application process in KAECSES. For other programs, a special medical indicator generally denotes QMB eligibility.
The following rules apply:
QMB Only - For persons who are eligible only for QMB coverage and are not eligible for any other form of medical assistance or attempting to meet a spenddown, eligibility is determined using the MS program and a medical program subtype of QO. Eligibility is authorized on MSID, except for persons who are eligible only because of the COLA is regard in the first few month of the calendar year. A special medical indicator of QO is used in these situations.
QMB + Medically Needy (Spenddown) - For persons eligible for QMB and also attempting to meet a spenddown, no medical program subtype is used. Eligibility is authorized on MSID, except for persons who are eligible only because of the COLA disregard in the first few months of the calendar year. When Medicaid is provided on the MS program, a special medical indicator of QS is used in these situations, regardless of whether the spenddown has actually been met.
When Medicaid is determined on an MA program, a Special Medical Indicator of QM is used.
QMB + Medicaid - For persons eligible for QMB and also eligible for full Medicaid (except Working Healthy), appropriate medical program subtypes necessary for other coverages are required (e.g., HC for HCBS or AC for LTC/NF) when Medicaid is provided on the MS program. Eligibility is authorized on MSID, except for persons who are eligible only because of the COLA disregard in the first few months of the calendar year. A special medical indicator of QM is used in these situations.
When Medicaid coverage is determined on a program other than MS (e.g., MA CM or MP), a special medical indicator of QM is used.
QMB + Working Healthy - For person eligible for QMB and Working Healthy, a medical program subtype of WH is used. Eligibility for both coverages is authorized using a special medical indicator of WQ.
2671.5 Benefits - Medical coverage for QMB only eligibles is limited to payment of Medicare Part A and Part B premium, deductibles and co-insurance. This applies to Medicare covered services and items covered by Medicaid and those which are not covered by Medicaid. Because of this, it is necessary to complete a QMB determination on persons eligible for full Medicaid coverage. QMB eligibles are subject to Medicaid copay requirements, unless otherwise exempt. QMB coverage is designated on the medical identification card.