32.2 Qualified Medicare Beneficiary

32.2.1 Introduction

The following Medicaid members are categorically eligible for QMB benefits:

People who are receiving or are eligible to receive SSI .
People who are eligible for categorically needy SSI-related Medicaid as a:
- 503 assistance group (as defined in Section 25.1 503 Eligibility).
- DAC (as defined in Section 25.2 Disabled Adult Child).
- Widow or widower (as defined in Section 25.3 Widows and Widowers).

Note: If a member is not eligible for categorically needy SSI-related Medicaid through any of these four groups, he or she is not automatically eligible for QMB benefits.

Example 1: Kate receives an SSDC payment from Social Security. Due to other unearned income, however, Kate is not eligible for categorically needy SSI-related Medicaid as a DAC. Even though she receives a “DAC” payment, she is not automatically eligible for QMB because she is not eligible for Medicaid through the receipt of SSI or through Special Status Medicaid.

A 503 assistance group, DAC, and widow or widower, as defined above, have the option of not taking the QMB benefit.

32.2.2 Entitled to Medicare

A person is "entitled" to Medicare Part A if he or she meets one of the following conditions:

He or she does not have to pay a premium for Medicare Part A and is enrolled in Medicare Part A as of the QMB determination.

Example 2: Mrs. Smith applies for QMB benefits August 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.

He or she must pay a monthly premium to receive Medicare Part A and fits one of the following descriptions:

1. He or she is a Medicaid member and has been enrolled in Medicare sometime in the past. In this case the State will attempt to enroll him or her in Medicare Part A. QMB eligibility cannot begin prior to the Part A begin date.

Example 3: Eleanor's Part A lapsed because she did not work enough quarters for free enrollment, and she could no longer afford the premiums. When she becomes eligible for Medicaid, the state will begin paying her Medicare premiums.

1. He or she is a Medicaid member or QMB or SLMB or QDWI applicant and has never been enrolled in Medicare Part A. In this case he or she must apply at the local SSA office for Part A Medicare eligibility. He or she will receive a receipt which entitles him or her to enrollment in Part A on the condition that he or she 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 prior to the Part A begin date.

Example 4: Pearl was never enrolled in the federal Medicare system. She applies for QMB. Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare. She goes to the SSA office during the January-March enrollment period and is conditionally determined eligible for Part A effective July 1st. She applies for QMB at the IM Agency on May 1st. She becomes QMB eligible as of July 1st.

32.2.3 Income Limit

The QMB income limit is 100% of the federal poverty level ( FPL ). See 39.5 FPL Table.

The method of counting income is based on the SSI method, not on the spousal impoverishment method. (See 28.1 HCBWLTC Introduction). Calculate QMB net income as follows:

$ Earned income (See 15.5 Earned Income)

- $65 and ½ earned income deduction (15.7.5 $65 and ½ Earned Income Deduction)

+ Unearned income (Social Security income, etc.) (15.4 Unearned Income)

- Special exempt income (15.7.2 Special Exempt Income)

- $20 standard deduction

= Net income used to determine QMB eligibility

When counting Social Security income, use the gross Social Security income. Gross Social Security income:

Of a self-payer = the Social Security check amount + Medicare premiums he or she has paid.
Of someone for whom the state is paying the premiums = the Social Security check amount.

Disregard the COLA increase for the current year until the month after the new federal poverty limits become effective.

Example 5: Al is a QMB member. He has income of 99% of the FPL. In January, a COLA increase of $15.00 increases Al's income above 100% of the FPL. Disregard the COLA increase in any determination of Al's continuing QMB eligibility. On April 1, new QMB income limits are published. Redetermine Al's QMB eligibility in May using the new QMB income limits. At this redetermination, do not disregard the January COLA increase.

This page last updated in Release Number: 17-03

Release Date: 11/03/2017

Effective Date: 11/03/2017