2672 Low Income Medicare Beneficiaries (LMB) - 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 coverage of Part B premiums only if:
Although the LMB program is, in essence, an extension of the QMB program,
except for the fact that benefits are limited to Part B premiums only,
persons qualifying for QMB are not also eligible for LMB. These are two
distinct programs and do not overlap. Persons whose income does not exceed
100% of the federal poverty level qualify only for QMB benefits (see 2671). For LMB, the eligible person's
income would need to fall between 100% and 135% of poverty.
The general guidelines regarding Part A eligibility and financial eligibility
for the QMB program as specified in and are applicable to LMB. This includes
the separate determination of eligibility as well as the disregard of
the Social Security cost-of-living adjustment in the first calendar quarter.
A one-month base shall be applicable to LMB determinations in accordance
with (1). Total countable income to be considered in the eligibility base
period shall be compared against the appropriate monthly poverty level
standard (see Appendix,
Item F-8). Eligibility exists if the countable income does not exceed
this level and resources are within the allowable level.
Eligibility for LMB coverage shall be established only in the MA and MS programs. Coverage allows for immediate buy-in of Medicare Part B premiums. LMB benefits can be provided for the month of application, future months and the prior eligibility period. There is no delayed effective date as with QMB. There are two different groups of eligible individuals that exists within the program as indicated below.
2672.1 Regular LMB (also known as the Specified Low-Income Medicare Beneficiary Program) - This program is for those individuals with income between 100% and 120% of poverty. The Part B premium for this group is subject to normal Medicaid state/federal match. A person may qualify for LMB-only or for coverage of premiums while in spenddown status or in a prior eligibility period. Persons eligible for SI or Poverty Level programs do not receive any additional benefit from LMB and are, therefore, not eligible except for prior medical coverage. This is due to the fact that the LMB program covers only Part B premiums and such persons are already covered for Part B buy-in.
To designate eligibility for LMB, the following rules apply:
LMB Only - For persons eligible for LMB only, who 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 LO. A special medical indicator of LO is used in these situations.
LMB + Medically Needy - For persons eligible for LMB who are also attempting to meet a spenddown, no medical program subtype is used. A special medical indicator of LS is used, regardless of whether the spenddown is met or unmet. LMB + Medicaid For persons eligible for LMB and full coverage Medicaid (except Working Healthy), appropriate medical program subtypes necessary for other coverages are required (e.g., HC for HCBS or AC for LTC). A special medical indicator of LM is used.
LMB + Working Healthy - For person eligible for LMB and Working Healthy, a medical program subtype of WH is used. Eligibility for both coverages is authorized using a special medical indicator of WL.
2672.2 Expanded LMB (also known as the
Qualifying Individual-1
Program) - This program is for those individuals with income between
120 and 135% of poverty. The Part B premium for this group is subject
to 100% federal funding based on federal law.
Persons are only eligible for Expanded LMB if they are not otherwise Medicaid eligible, or attempting to gain Medicaid eligibility. However, once established, an individual eligible for Expanded LMB can later seek full Medicaid if such a need arises. For example, if the individual applies for HCBS and is approved for services, Expanded LMB coverage should be closed as soon as possible given timely notice deadlines. Prior medical coverage may also be provided in these instances.
For persons eligible for Expanded LMB, a medical program subtype of LO is used, and a Special Medical Indicator of LL should be entered on the PICK screen in KAECSES to denote eligibility for Expanded LMB. The code shall always be retained in the system as long as the person remains eligible for such coverage.
2673 Reserved