400.05.02 MEDICARE COST-SHARING GROUP – QMB (QUALIFIED MEDICARE

BENEFICIARY) COE-031 Section 301 of the Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360) mandated coverage of Qualified Medicare Beneficiaries (QMB's) for the purpose of Medicare cost-sharing expenses. The QMB provision of federal law was effective January 1, 1989; however, Mississippi required state enabling legislation to add the coverage group which delayed the implementation of the QMB provision until July 1, 1989. At the time of implementation, the resource limit for QMB’s was twice the SSI resource limits; however, effective 07/01/1999, liberalized policy removed the resource test for the Medicare cost-sharing groups of QMB, SLMB and QI. The QWDI group retained the resource limit equal to twice the SSI limits. A QMB must meet all non-financial requirements of Medicaid eligibility. The exception is a DDS determination of disability for an individual under age 65. Medicare entitlement is proof of disability per policy outlined in Section 102, Non-Financial Requirements. To qualify for QMB coverage, an individual or couple must meet all of the following criteria: • Each eligible individual must be entitled to Medicare Part A (Hospital Insurance). Individuals with Medicare Part B only can be considered for QMB eligibility since Medicaid will enroll the individual in Part A and pay the Part A premium. Refer to “Medicare Entitlement for QMB-Only” below for further information. Note: The only exception to requirement of enrollment in Part A is individuals entitled to Medicare Part B-ID. Medicare Part B-ID, implemented January 2023 from the Consolidated Appropriations Act 2021, is solely for coverage of immunosuppressive drugs. Part B-ID may be awarded to individuals who lose Medicare entitlement based on end stage renal disease (ESRD) 36 months following a successful kidney transplant. Individuals are ineligible for Part B-ID if they have full Medicaid coverage that includes coverage for immunosuppressive drugs or other health insurance. • Countable income cannot exceed 100% of the FPL. • There is no resource test, but income produced by resources (interest, dividends, etc.) counts as income. Refer to Chapter 200, Income, at 200.02.02, Types of Income. Verification of this income must be provided by the applicant. Effective Date of QMB Benefits Medicare cost-sharing benefits are effective with the month after the month in which a determination is made that the individual is eligible as a QMB. For example, a QMB application authorized in the system on February 5th will have QMB eligibility beginning March 1st. Retroactive benefits are not permissible for QMB-only applicants. It is not permissible to place a QMB-only individual in another COE for the retroactive period (such as SLMB or QI). An individual can be placed in an alternate COE for the retroactive period only if the individual qualifies in a non-Medicare cost-sharing COE. If a QMB application is not approved timely due to agency error, a QMB-override function is available in MEDS to correct the beginning date of QMB eligibility. QMB Benefits An individual or couple eligible as QMB-only receives the following Medicare cost- sharing benefits: • Payment of monthly Medicare Part A premiums, if applicable. • Payment of monthly Medicare Part B premiums or • Payment of monthly Medicare Part B-ID premiums and • Payment of Medicare Parts A/B deductibles and co-insurance. Payment of the Medicare Part A and Part B or B-ID premiums begins the month QMB- only coverage begins. QMB Dual Eligibility An individual can be eligible as a QMB and eligible in another full-service COE. Eligibility as a QMB can constitute an eligibility status which is in addition to eligibility under another Medicaid full-service coverage group. When an individual is eligible as a QMB and in another category, this is known as QMB dual eligibility. A recipient dually eligible as a QMB and in another full-service COE receives the full range of Medicaid services and Medicare cost-sharing benefits also, i.e., payment of Medicare Part A premiums, payment of Medicare Part B premiums, payment of Medicare Part A/B deductibles and co-insurance charges. Since the primary eligibility is under the full-service Medicaid COE, the individual must be eligible using the eligibility criteria for the primary COE as well as eligibility for QMB. The following examples illustrate: Example 1: An aged applicant in a nursing facility has Medicare Parts A and B. Total countable income is $900 in Social Security benefits; countable resources total $3,500 and all non-financial eligibility factors are met. Eligibility for long term care in a nursing facility is established. The individual is eligible in a long-term care COE and is also eligible for QMB status since income does not exceed 100% FPL. The individual is a QMB- dual and qualifies for full Medicaid coverage, including payment to the nursing facility for long term care services plus the full array of Medicare cost-sharing services. Example 2: Same example as Example #1 but individual has $15,000 in countable resources. In this situation, the individual does not qualify for long term care services but can qualify for QMB-only until such time as resources are reduced to $4,000 or less. Example 3: A disabled applicant meets all necessary criteria for Disabled Adult Child (DAC) coverage. His countable income, after his DAC disregard, totals $400. He meets SSI financial and non-financial requirements. He also has Medicare Parts A and B. He qualifies as both a DAC and a QMB, thus he has QMB dual coverage. Example 4: An aged applicant is working and qualifies as a Working Disabled individual. His Social Security is $800, and his earnings are $500 each month. His countable Social Security is $750, and his countable earnings are $217.50, which puts him below 100% FPL. He has Medicare Part A/B and qualifies as both a Working Disabled and QMB. Applicant’s Choice of Category An individual who would be eligible as a QMB and under another non-Medicare cost- sharing COE may choose to have eligibility determined under only one category; however, the individual is not required to make such a choice. The applicant is entitled to have eligibility determined under all categories for which he may qualify, such as QMB dual status as shown in the examples above. However, an individual who would be eligible under more than one category can request to have eligibility determined only under the category he selects. NOTE: LIS applicants with income that does not exceed 100% of the FPL are considered to be applying for QMB-only. Medicare Entitlement for QMB-Only An applicant for QMB-only must be “entitled” to Medicare Part A even if the individual is not eligible for free Part A. Applicants with countable income at a budget level that does not exceed 100% of the FPL (potential QMB-only individuals) must accept Medicare Part A under the condition that Medicaid will pay the Part A premium. The effective date of Part A coverage should be entered in the system as the effective date of QMB coverage. Refer identifying information to TPL to the Director of the Buy-In program to get the process of opening Medicare Part A through the Buy-In process. QMB-only applicants may have: Medicare Part A only The Buy-In process will enroll the applicant in Medicare Part B after approval of the QMB-only case. Medicare Part B only Applicant must apply for Medicare Part A under condition that Medicaid will pay the premium. If applicant has previously applied for Medicare and refused, withdrew or was terminated due to non-payment – notify Director of Buy-In as stated above to get Part A opened or reopened through the Buy-In process. Part A effective date is equal to QMB-Only effective date. Medicare Parts A and B Enter data in MEDS, no further action needed. Medicare Part B-ID The Buy-In process will pay Part B-ID monthly premiums and Part B-ID cost-sharing.