Revision 09-4; Effective December 1, 2009

§359.101. Purpose and Scope.

(a) This chapter describes the assistance available and eligibility requirements for the Medicare Savings Program. Authorized under 42 U.S.C. §1396a(a)(10)(E), the Medicare Savings Program uses Medicaid funds to help eligible persons pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.

(b) The Texas Health and Human Services Commission (HHSC) manages the Medicare Savings Program, which consists of the following:

(1) the Qualified Medicare Beneficiary (QMB) Program;

(2) the Specified Low-Income Medicare Beneficiary (SLMB) Program;

(3) the Qualified Individual (QI) Program; and

(4) the Qualified Disabled and Working Individual (QDWI) Program.

(c) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.

§359.103. Qualified Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(i), the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles, and coinsurance for a person who meets the requirements of this section. A person receiving Medicaid may also receive QMB benefits if the person meets the requirements of this section.

(b) To be eligible for QMB coverage, a person must:

(1) be entitled to benefits under Medicare Part A; and

(2) meet income and resources requirements in 42 U.S.C. §1396d(p).

(c) A person is not eligible for QMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's QMB eligibility begins on the first day of the month after the month the person is certified for QMB benefits.

(e) A person with QMB coverage is not eligible for three months prior medical coverage.

§359.105. Specified Low-Income Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iii), the Specified Low-Income Medicare Beneficiary (SLMB) Program pays only Medicare Part B premiums for a person who meets the requirements of this section. A person receiving Medicaid may also receive SLMB benefits if the person meets the requirements of this section.

(b) To be eligible for SLMB coverage, a person must meet the eligibility criteria for QMB coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have an income that is greater than 100% but less than 120% of the federal poverty level.

(c) A person is not eligible for SLMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's SLMB eligibility may begin with the month of application.

(e) A person with SLMB coverage is eligible for three months prior medical coverage, if all criteria are met.

§359.107. Qualifying Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iv) the Qualifying Individual (QI) Program pays only Medicare Part B premiums to a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QI coverage at the same time.

(b) To be eligible for QI coverage, a person must meet the eligibility criteria for Qualified Medicare Beneficiary coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have income that is at least 120% but less than 135% of the federal poverty level.

(c) Eligibility for QI coverage is determined for each calendar year.

(d) A person's QI eligibility may begin with the month of application.

(e) A person with QI coverage is eligible for three months prior medical coverage if all criteria are met. The three-month prior period cannot extend back into the previous calendar year.

§359.109. Qualified Disabled and Working Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(ii), the Qualified Disabled and Working Individual (QDWI) Program pays only Medicare Part A premiums for a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QDWI coverage at the same time.

(b) To be eligible for QDWI coverage, a person must:

(1) be under 65 years of age;

(2) be entitled to benefits under Medicare Part A;

(3) not otherwise be eligible for Medicaid;

(4) have a monthly income equal to or less than 200% of the federal poverty level; and

(5) have no more than twice the countable resources allowed under the Supplemental Security Income (SSI) program, as described in §1611 of the Social Security Act (42 U.S.C. §1382).

(c) A person's QDWI eligibility begins in accordance with the coverage period described in §1818A of the Social Security Act (42 U.S.C. §1395i-2a(c)).

Revision 22-3; Effective September 1, 2022

MIPPA added requirements for processing MSP applications for people applying through the Social Security Administration (SSA) for the Low Income Subsidy (LIS) program, also referred to as the Extra Help program. LIS provides prescription assistance for Medicare beneficiaries enrolled in Medicare Part D who have limited income and resources. The MSP programs included in MIPPA are:

• Qualified Medicare Beneficiary (QMB) Program;
• Specified Low-Income Medicare Beneficiary (SLMB) Program; and
• Qualified Individual (QI) Program.

The Qualified Disabled and Working Individual (QDWI) Program is not part of MIPPA.

Texas receives a list of people who applied for LIS from SSA. The list includes whether the people were approved or denied. The date the Texas Health and Human Services Commission (HHSC) receives the list is the application date for MSP and starts the 45-day clock for timely processing of the applications for each person on the list. The date the application was made with SSA is a protected file date for MSP eligibility. Form H1200-EZ, Application for Assistance — Aged and Disabled is sent to each person on the list. HHSC sends denied LIS applicants a denial notice with the right to appeal if they are denied because they:

• live outside the United States;
• have excess resources; or
• have excess income (couples will not auto deny).

Additionally, TIERS will deny anyone identified as living outside of Texas.

Revision 24-1; Effective March 1, 2024

QMB, SLMB and QI Resource Limits

The resource limits for the following Medicare Savings Programs (MSP) are based on the annual consumer price index (CPI). They are updated in January of each year:

• Qualified Medicare Beneficiary (QMB);
• Specified Low-Income Medicare Beneficiary (SLMB); and
• Qualified Individual (QI).

Use the following resource limits when determining eligibility for these programs.

Date Range	Individual	Couple
Jan. 1, 2024 to Present	$9,430	$14,130
Jan. 1, 2023 to Dec. 31, 2023	$9,090	$13,630
Jan. 1, 2022 to Dec. 31, 2022	$8,400	$12,600
Jan. 1, 2021 to Dec. 31, 2021	$7,970	$11,960
Jan. 1, 2020 to Dec. 31, 2020	$7,860	$11,800
Jan. 1, 2019 to Dec. 31, 2019	$7,730	$11,600
Jan. 1, 2018 to Dec. 31, 2018	$7,560	$11,340
Jan. 1, 2017 to Dec. 31, 2017	$7,390	$11,090
Jan. 1, 2016 to Dec. 31, 2016	$7,280	$10,930
Jan. 1, 2015 to Dec. 31, 2015	$7,280	$10,930
Jan. 1, 2014 to Dec. 31, 2014	$7,160	$10,750
Jan. 1, 2013 to Dec. 31, 2013	$7,080	$10,620
Jan. 1, 2012 to Dec. 31, 2012	$6,940	$10,410
Jan. 1, 2011 to Dec. 31, 2011	$6,680	$10,020
Jan. 1, 2010 to Dec. 31, 2010	$6,600	$9,910
Jan. 1, 1989 to Dec. 31, 2009	$4,000	$6,000

QDWI Resource Limits

The resource limits for Qualified Disabled and Working Individuals (QDWI) are twice the resource limits for the SSI program.

Use the following resource limits when determining eligibility for the QDWI program:

• $4,000 for an individual; and
• $6,000 for a couple.

Related Policy

Resource Limits, F-1300
Medicare Savings Program Information, Appendix IX
Budget Reference Chart, Appendix XXXI

Revision 20-3; Effective September 1, 2020

The income limits for QMB, SLMB and QI are based on the federal poverty level (FPL), which is adjusted annually. The Social Security cost-of-living adjustment (COLA) is excluded through the month in which the annual revision of the FPL is published. To determine eligibility for applications and redeterminations, use the pre-COLA benefit amount during those months.

For example, if the FPL is published in February, exclude the RSDI COLA for the months of January and February.

Reminder: The COLA exclusion does not apply when determining eligibility for the QDWI program.

Related Policy

Deeming Income, E-7000
QDWI Cost-of-Living Adjustment, Q-6300