Q-2000, Qualified Medicare Beneficiaries (QMB) – MC-QMB

Revision 20-3; Effective September 1, 2020

 

The Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles and coinsurance for a person who meets the requirements of this section.

To be eligible for QMB coverage, a person must:

  • be entitled to benefits under Medicare Part A; and
  • meet income and resources requirements.

The income limits for QMB are based on 100 percent of the federal poverty level (FPL), and are updated annually.

The resource limits are based on the consumer price index and are updated annually.

The person must provide proof of Medicare Part A entitlement to enroll for Medicare Part A. They may have a Medicare card or an enrollment letter from the Social Security Administration (SSA) showing entitlement to Part A.

If the person has no proof of entitlement, refer them to SSA for Part A enrollment if they:

  • are age 65;
  • have a disability (as determined by SSA); or
  • have chronic renal disease.

The person must enroll themselves. HHSC is not allowed to enroll the person for Part A as it can for Part B.

A person receiving Medicaid may also be eligible for QMB benefits if they meet the requirements of this section, including the following recipients:

  • people of any age residing in a state supported living center;
  • people age 65 or older residing in a state hospital; and
  • people of any age residing in an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID).

 

Related Policy
Medicare Savings Program Information, Appendix IX
Qualified Medicare Beneficiary (QMB), A-8100
Medicare Savings Programs Overview, Q-1000
MSP Resource Limits, Q-1300
QMB Income Limits, Q-2500
QMB Medical Effective Date, Q-2700
Qualified Disabled and Working Individuals (QDWI) – MC-QDWI, Q-6000

 

 

Q-2100 Verification and Documentation for QMB

Revision 09-4; Effective December 1, 2009

 

Acceptable verification for Medicare enrollment for Part A includes:

  • Wire Third Party Query (WTPY);
  • State On line Query (SOLQ);
  • Medicare card;
  • an enrollment letter from the Social Security Administration documenting enrollment in Part A; and
  • presumptive eligibility (persons age 65 years and older receiving RSDI or Railroad Retirement can be presumed enrolled in Medicare Part A, unless their Social Security claim number suffix ends in J3, J4, K3, K4, K7, K8, KB, KC, KF, KG, KL and KM).

 

Q-2200 Conditional QMB

Revision 09-4; Effective December 1, 2009

 

Texas is a "buy-in" state. There is no restricted enrollment period. HHSC can automatically "add on" a person's Medicare Part A entitlement and pay the Medicare Part A premium at any time during the year. In other words, if the applicant has Part A, is enrolling for Part A or is entitled to Part A, the applicant may be certified for QMB.

 

Q-2210 Upon Certification of QMB

Revision 09-4; Effective December 1, 2009

 

  • If the person has Part B only (or is enrolling for Part B), the state will add on the person's Part A entitlement.
  • If the person has Part A only, the state will automatically add on the Part B entitlement.
  • The state will not pay any expenses until Part A and B premiums begin.

The only "conditional" left is if a person does not have Part A or B. However, we do not have to wait to put the person on QMB.

 

Q-2300 Social Security Administration QMB Referral Procedures

Revision 10-4; Effective December 1, 2010

 

Although most people who are eligible for Medicare Part A receive free Part A coverage, some are required to pay a monthly premium.

A person is entitled to Medicare Part A if the person meets one of the following conditions:

  • The person does not have to pay Medicare Part A, and is receiving Medicare Part A services as of the QMB determination.

    Example: Mrs. Smith applies for QMB benefits Aug. 15. She has a Medicare card with a Part A begin date of June 1. Since Medicare will pay for Part A services as of June 1, she is entitled to Part A at the time of the QMB determination.
  • The person is a Medicaid recipient or QMB or Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Disabled and Working Persons (QDWI) applicant and has never been enrolled in the federal Medicare system. In this case the person must apply at the local Social Security Administration (SSA) office for Part A Medicare eligibility. The person will receive a receipt that entitles the person to enrollment in Part A on the condition that the person is found eligible for QMB or SLMB. The receipt from SSA will have a Part A begin date on it. QMB or SLMB or QDWI eligibility cannot begin before the Part A begin date.

    Example: Mrs. Brown was never enrolled in the federal Medicare system. She applies for QMB. The eligibility specialist takes her application and pends it. Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare. She contacts SSA and is conditionally determined eligible for Part A. Her QMB application is completed.

The eligibility specialist may receive a referral from SSA. An application will be sent to a person with conditional Part A enrollment if there is not a current pending QMB application already on file.

The person's Wire Third Party Query (WTPY) verifies conditional Part A enrollment when the Social Security claim number ends in M and:

  • the Part A payment code status is Z99 and there is an entitlement date to Medicare Part B; or
  • there is no entitlement date for Part A and there is an entitlement date to Part B.

Proof of conditional enrollment in Part A fulfills the QMB eligibility requirement of entitlement to Medicare Part A.

Note: Do not presume that a person enrolled in Medicare Part B is also enrolled in Medicare Part A. Persons drawing early retirement (RSDI) (usually at the age of 62) are not eligible for Medicare Part A or B. Persons determined disabled by SSA and under age 65 are not eligible to enroll in Medicare until they have been disabled for 24 consecutive months or reach their 65th birthday, whichever comes first.

 

Q-2400 QMB Benefits

Revision 12-2; Effective June 1, 2012

 

QMB recipients do not receive regular Medicaid benefits. HHSC sends these persons a Your Texas Benefits Medicaid Card that reflects QMB status.

Medicaid pays out-of-pocket Medicare cost-sharing expenses for QMB recipients. Medicaid does not limit deductible or coinsurance payments to services covered by the State Plan.

 

Q-2500 QMB Income Limits

Revision 20-3; Effective September 1, 2020

 

Monthly income must be not more than 100 percent FPL.

Use the couple income range when both spouses are applying for the same program.

The monthly income limits for the QMB program are:

Date Range Individual Couple Deeming*
March 1, 2020 to Present $1064 $1437 $373
March 1, 2019 to Feb. 29, 2020 $1041 $1410 $369
March 1, 2018 to Feb. 28, 2019 $1012 $1372 $360
March 1, 2017 to Feb. 28, 2018 $1005 $1354 $349
March 1, 2016 to Feb. 28, 2017 $990 $1,335 $345
March 1, 2015 to Feb. 29, 2016 $981 $1,328 $347
March 1, 2014 to Feb. 28, 2015 $973 $1,311 $338
March 1, 2013 to Feb. 28, 2014 $958 $1,293 $335
March 1, 2012 to Feb. 28, 2013 $931 $1,261 $330
March 1, 2011 to Feb. 29, 2012 $908 $1,226 $318
March 1, 2009 to Feb. 28, 2011 $903 $1,215 $312

Note: These amounts do not include the $20 disregard.

*The deeming allowance is the couple limit minus the individual limit.

 

Related Policy
MSP Resource Limits, Q-1300
Budget Reference Chart, Appendix XXXI

 

Q-2600 Reserved for Future Use

Revision 20-3; Effective September 1, 2020

 

 

 

Q-2700 QMB Medical Effective Date

Revision 12-4; Effective December 1, 2012

 

QMB eligibility begins on the first day of the month following the month the person is determined eligible for QMB benefits. The disposition date in the system of record is the date the eligibility decision is completed. For example, if the MC – QMB is signed and disposed on Jan. 2, QMB eligibility would begin on Feb.1.

There is no QMB coverage in the three months prior to the QMB application date or coverage for months up to the QMB effective date. The only exception is if the individual is eligible for continuous QMB. See details listed in Section Q-2800, Ensuring Continuous QMB.

 

Q-2710 Prior Coverage Under SLMB/QI-1

Revision 12-2; Effective June 1, 2012

Institutional living arrangement (including persons residing in state supported living centers and ICF/ID facilities, and persons age 65 and over residing in institutions for mental diseases (IMDs)).

Situation 1

A person does not reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Situation 2

A person does reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income, such as additional income was received in the prior months.

Note: Deeming and support and maintenance is not applicable to institutional or Home and Community-Based Services waiver programs but is applicable to QMB, SLMB, and QI-1.

Living in the community, including persons applying for Community Attendant Services (CAS) and persons residing at home and applying for Home and Community-Based Services waiver programs:

Situation

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual's income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Reminder

QI-1 persons cannot be eligible for regular Medicaid and QI-1 benefits at the same time. Always give applicants the opportunity to choose which benefit they prefer to receive and document the person's verbal or written choice of preferred benefit, including a choice between QI-1 and CAS benefits. For QI-1, the three months prior period cannot extend back into the previous calendar year unless the application was filed in that calendar year. The application file date and prior coverage months must be in the same calendar year.

Example 1: February is the application month, which makes January the only possible prior coverage month.

Example 2: December is the application month; thus, the three months prior would be September, October and November. Applicant could be potentially eligible for the three months prior, the application month of December and for January and ongoing.

 Note: Refer to Section Q-3400, SLMB Medical Effective Date, for policy regarding the prior months.

 

Q-2800 Ensuring Continuous QMB

Revision 13-4; Effective December 1, 2013

 

If a denied SSI recipient applies for Medicaid under an MEPD program, verify whether the individual was also receiving QMB benefits at the time of the SSI denial by viewing the individual’s Medicaid History or Eligibility History in TIERS Inquiry. Verification also can be obtained by SOLQ/WTPY.

If a person is eligible for QMB and is applying for MC-QMB, enter the Continuous QMB Begin Month in the Program – Individual page in the system of record. This ensures continuous QMB coverage.

Examples:

  • The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is being certified under ME-Pickle and MC-QMB.
  • The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is certified under MC-QMB.

Technically, there is no limit as to how far back continuous QMB coverage may be given. However, system limitations will not allow Medicare Part B buy-in reimbursement to begin any earlier than two full fiscal years (with September considered the start of a fiscal year). The earliest buy-in date is based on the date that the buy-in process is successfully completed (not the eligibility specialist's decision date, the person's medical effective date [MED], or QMB effective date).

 

Examples:

  • SSI/QMB coverage denied Dec. 31, 2007
    Form H1200, Application for Assistance – Your Texas Benefits, filed April 7, 2010
    Eligibility determined on May 15, 2010, for continuous QMB; QMB MED = Jan. 1, 2008; buy-in process completed on July 15, 2010; buy-in effective January 2008 (current full fiscal year does not end until August 2010; earliest full fiscal year began September 2007)
  • SSI/QMB coverage denied Dec. 31, 2007
    Form H1200 filed Aug. 15, 2010
    Eligibility determined on Sept. 11, 2010, for continuous QMB; QMB MED = Jan. 1, 1998; buy-in process completed on Nov. 15, 2010; buy-in effective September 2008 (current full fiscal year began September 2010; earliest full fiscal year began September 2008)

If the QMB medical effective date precedes the earliest available buy-in date, the person can receive Medicaid coverage for Medicare co-payments and deductibles for the entire period established by the medical effective date. Buy-in coverage would begin later. A person may elect not to have continuous coverage if the medical effective date will not provide buy-in for the entire period and the person does not have any claims to cover or be reimbursed.

What is not considered continuous QMB:

  • QMB recipient was denied in error because income was incorrectly counted in the budget. The case needs to be corrected to add the missing coverage the recipient is entitled to receive.
  • QMB recipient was correctly denied for exceeding the income or resource limits. This is a valid denial and a break in coverage. These individuals cannot have continuous coverage if they reapply and are again eligible for QMB. The QMB effective date would be the first of the month after disposition.
  • QMB recipient was denied because the redetermination packet was lost or misrouted in the task list manager queue. The case needs to be corrected to add the missing coverage the recipient is entitled to receive.
  • QMB recipient was denied at redetermination for no packet received. At reapplication, this is not a continuous QMB, as the denial was valid. The QMB effective date would be the first of the month after disposition.

 

Q-2900 QMB Eligibility and Supplemental Security Income

Revision 13-4; Effective December 1, 2013

 

Persons receiving Medicaid benefits under SSI also may qualify for QMB. QMB status is automatically added to the Medicaid coverage when the person also receives Medicare Part A. QMB eligibility is effective the month after the tape match from SSA is received.

Example: The tape match with SSA is received in September 20XX indicating the SSI recipient is Medicare Part A eligible August 20XX. QMB eligibility will begin in October 20XX.

In situations where the SSI recipient should have QMB coverage but does not, the eligibility specialist emails all inquiries or necessary updates to CCC_Data_Integrity_Program@hhsc.state.tx.us. The turnaround time is 24 to 36 hours, depending on the number of inquiries received. Send the following information with your request:

  • Individual's number
  • Individual's name
  • Case number and EDG number
  • Medical coverage requested, including certification period
  • Add or delete coverage requested
  • Any special instructions that have to do with Medicaid coverage