Basic Considerations

To be eligible under this COA an A/R must meet the following conditions:

The A/R is enrolled in Medicare Part A, Parts A and Part B, or Part B only.

The A/R meets all basic eligibility criteria. Applicants/Recipients who are entitled to or enrolled in Medicare are exempt from the citizenship verification requirement. Citizenship was verified by SSA prior to awarding Medicare. A Declaration of U.S. Citizenship is still required. Individuals who attest to satisfactory immigration status must have their immigration status verified through SAVE as there are some differences in the immigrant eligibility between Medicare and Medicaid. Length of Stay (LOS) and Level of Care (LOC) are not requirements under this COA.

The A/R has countable resources of less than or equal to the current QMB/SLMB/QI-1 resource limit.

The A/R has countable net income of less than or equal to the QMB income limit.

QMB pays the following for the QMB eligible individual:

the monthly premium for Part A Medicare for those individuals who must pay a premium

the monthly premium for Part B Medicare

all Medicare co-insurance payments (the 20% of covered charges that Medicare will not pay)

all Medicare deductibles, such as the in-patient hospital deductible

Effective for dates of service on or after May 11, 2012, payments for Medicare coinsurance, copayments, and deductibles for dual Medicare/Medicaid members, including QMB, will be limited to the Medicaid maximum allowable amount. If the Medicare payment on a claim is equal to or greater than the Medicaid maximum allowable amount, Medicaid will not pay anything on the claim. All Medicare providers are prohibited from billing QMB recipients for Medicare cost-sharing. This includes Medicare coinsurance, copayments, and deductibles. (See Special Considerations at the end of this section.)

QMB will not cover any medical service that is not covered by Medicare.

Applicants for QMB must meet all eligibility criteria for this COA in the month of approval and the following month in order to be approved.

There is no retroactive coverage under this COA. QMB eligibility begins the first day of the month following the month the eligibility determination is completed.

If the individual is enrolled in Part B, but not Part A, determine them eligible for QMB if they otherwise meet the eligibility criteria.

If an individual is age 65 or older and neither enrolled in Part A nor Part B, direct the individual to file a conditional Part A application at SSA for the purposes of applying for QMB. Individuals can conditionally enroll in Part A at SSA at any time of the year, without regard to Medicare enrollment periods.

The conditional enrollment process allows an individual to apply for premium Part A at SSA on the condition that they will only be enrolled in Part A if the individual then applies for Medicaid at DFCS and is determined eligible for QMB. If DFCS determines the individual ineligible for QMB, SSA will not establish Part A entitlement.

As part of the conditional Part A application, SSA will enroll an individual in Part B.

SSA will process applications for Part B Medicare without regard to QMB eligibility.

An individual who has income less than the FBR may be eligible for QMB and not eligible for SSI because of excess resources.

In-kind Support and Maintenance (ISM) is not considered in determining QMB eligibility.

The QMB income limit is based on the FPL. The FPL/QMB income limit is subject to change between February and April of each year. Therefore, the annual January RSDI COLAs are disregarded in determining QMB eligibility until the effective month of the new QMB income limit.

Refer to Special Considerations in this section for procedures on processing the QMB application for SSI individuals.

THE STANDARD OF PROMPTNESS FOR QMB APPLICATIONS IS 10 WORKING DAYS FROM RECEIPT OF THE APPLICATION.

The 1999 Government Performance Results Act simplified the policy and procedures for this class of assistance and has changed the application process. In addition to applying at the county office, an A/R may apply with the local Community Health Center or with Georgia SHIP (formerly known as GeorgiaCares) on a simplified application on Form 700 -Application for Medicaid & Medicare Savings for Qualified Beneficiaries . (County DFCS shall also use this application form which is available from Central Supply.)