h-1100 qualified medicare beneficiary (qmb)

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 1 of H-1100

Replacing April 9, 2020

Revised/added text indicated by underscore Deleted text indicated by “”

H-1100 QUALIFIED MEDICARE BENEFICIARY (QMB)

H-1110 GENERAL INFORMATION

Effective January 1, 1988, the Medicare Catastrophic Coverage Act of

1988 required expansion of Medicaid coverage for a mandatory

eligibility group of low-income Medicare beneficiaries called Qualified

Medicare Beneficiaries (QMB).

The applicant/beneficiary must meet all of the following QMB

requirements. A QMB must:

• Be entitled to or enrolled in hospital insurance benefits under

Medicare Part A, but is not required to be enrolled in Medicare

Part B.

Note:

Supplemental Security Income (SSI) recipients who reach

age 65 are automatically entitled to Medicare. Enrollment

will be effective at the time the State begins to pay the

premium through Buy-In.

Note:

Any individual with a Beneficiary Identification Code (BIC) of

M is entitled to Medicare Part A and should be considered

for QMB. The alphabet code following the SSN in a

Medicare Claim Number is referred to as a BIC.

• Have income that is less than or equal to 100 percent of the

Federal Poverty Income Guidelines (FPIG). Refer to Z-200

Federal Poverty Income Guidelines.

Note:

In January of each year, disregard the Social Security

Administration (SSA) cost-of-living adjustment (COLA)

through the month following the release of the annual FPIG

update. For example, the annual FPIG is released in

January, disregard COLA through February. Thereafter,

determine eligibility using all income including the COLA for

that year.

• Meet all non-financial eligibility requirements for Medicaid.

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 2 of H-1100

Replacing April 9, 2020

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H-1110.1 Coverage

QMB eligibles are divided into two categories:

QMB Only

Eligible for Medicaid payments for:

• Medicare Part A (when applicable) and B premiums;

• Medicare deductibles for Medicare covered services; and

• Medicare coinsurance for Medicare covered services.

QMB Plus

Eligible for Medicaid payments for:

• The same benefits listed for QMB Only; plus

• The full range of Medicaid services.

Individuals who qualify for one of the Medicare Saving Programs

(QMB, SLMB, or QI) are automatically enrolled in the SSA low-

income subsidy (LIS) program (also called Extra Help). This subsidy

helps pay for the Medicare Part D prescription drug plan premiums, co-

payments, and the annual deductible. For more information on

LIS/Extra Help, please visit the Social Security Administration Extra

Help website.

Note:

Although the BHSF Form 1-MB, Application for Medicare

Savings Program, is commonly used to apply for QMB, it is

acceptable to use BHSF Form 1-A, Application for Health

Coverage.

SSI recipients do not have to apply for QMB. When Part A

eligibility is received through the data exchange , the individual

is automatically certified for QMB. If the SSI recipient who is

entitled to enroll in Part A is not automatically certified, enter the

QMB certification.

A beneficiary who is no longer eligible for full Medicaid may continue to

be eligible as a QMB Only.

SSI/QMB Plus beneficiaries remain eligible for QMB after entering a

long-term care (LTC) facility.

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 3 of H-1100

Replacing April 9, 2020

Revised/added text indicated by underscore Deleted text indicated by “”

H-1121 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements

have been listed in the most logical order, but work on all steps

simultaneously.

H-1121.1 Determine Assistance Unit

The assistance unit includes the applicant(s)/beneficiary(s).

H-1121.2 Establish Categorical Requirement

Verify entitlement/enrollment in Medicare Part A for the

applicant/beneficiary. Medicare Part A eligibility, the start date for

Medicare Part A, and the Medicare claim number may be verified

through the interfaces available in LaMEDS.

H-1121.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance unit with regard to

the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Enumeration I-600

• Residence I-1900

H-1121.4 Establish Need

A. Determine Composition of the Income Unit

The income unit includes the:

• Applicant/beneficiary;

• Applicant/beneficiary and ineligible spouse living in the same

home; or

• Applicants/beneficiaries who are a couple living in the same

home (eligible couple).

Note:

If SSA considers the applicant/beneficiary and their spouse

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 4 of H-1100

Replacing April 9, 2020

Revised/added text indicated by underscore Deleted text indicated by “”

as a couple for SSI, they are considered as an eligible

couple for the purposes of budgeting in the Medicare

Savings Programs ( QMB, SLMB, QI). An eligible spouse is

one who is aged, blind, or disabled and lives in the same

household as the applicant/beneficiary. The eligible spouse

does not have to be entitled to Medicare for the couple to be

considered an eligible couple.

B. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with

an ineligible spouse with no income, complete the following budget

steps:

Step 1. Determine the total gross unearned income.

Step 2. Subtract the $20 SSI general income disregard from

unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross

earnings.

Step 6. Subtract earned income deduction from remaining gross

earnings. Earned income deduction is $65 and one-half

of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Add remainders from Step 3 and Step 7.

Step 9. Compare the total to 100 percent FPL for one person.

Refer to Z-200 Federal Poverty Income Guidelines.

If the remaining income is greater than the QMB income limit for

one person, the applicant/beneficiary is not income eligible.

If the remaining income is equal to or less than the QMB income

limit for one person, the applicant/beneficiary is income eligible for

QMB.

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 5 of H-1100

Replacing April 9, 2020

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Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget Steps

1 through 9 above using only the applicant/beneficiary income. If

the income of the applicant/beneficiary is greater than the QMB

limit for one person, the applicant/beneficiary is ineligible and there

is no deeming. Consider for the Medically Needy Program (MNP).

If the income of applicant/beneficiary is equal to or less than the

QMB limit for one person, apply deeming policy. Refer to I-1420

Need - Deeming. Go to Step 1 of the couple budget.

Couple

If both members of a couple are potentially eligible, or if there is

income remaining in the deeming process, complete the following

budget steps:

Step 1. Determine the total gross unearned income by combining

the couple’s unearned income.

Note:

When deeming income from an ineligible spouse, the

income of the ineligible spouse remaining after

allocation for ineligible children is combined with the

income of the eligible spouse. The couple is then

treated the same as an eligible couple for budgeting

purposes.

Step 2. Subtract the $20 SSI general income disregard.

Step 3. The remainder is the couple’s countable unearned

income.

Step 4. Determine the total gross earned income by combining

the couple’s gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from

gross earnings.

Step 6. Subtract one earned income deduction from the

remaining gross earnings of the income unit. The earned

income deduction is $65 and one-half of the remainder of

the earnings.

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 6 of H-1100

Replacing April 9, 2020

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Step 7. The remainder is the couple’s countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare the total countable income to 100 percent FPL

for two persons. Refer to Z-200 Federal Poverty Income

Guidelines.

If the income is greater than the QMB income limit for two persons,

the applicant/beneficiary is not eligible.

If the income is equal to or less than the QMB income limit for two

persons, the applicant/beneficiary is income eligible.

Exception:

Couples in a nursing facility or receiving waiver services who

are being considered as individuals, are considered

individuals for QMB need/countable income determinations.

Refer to MEM 831.4

If one spouse is in a nursing facility or receiving waiver services

and his community spouse is not receiving waiver services,

determine eligibility for each spouse as an individual. Consider

income of each individual for separate QMB decisions.

Note:

Count as unearned income to the community spouse any

income allocated from an institutionalized spouse.

H-1121.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make

eligibility decision.

H-1121.6 Certification Period

Eligibility for QMB shall not be retroactive from the application date.

The certification period shall not exceed 12 months.

QMB certifications are effective the month following the month the

individual is determined to be QMB-eligible. The “month the individual

is determined to be QMB-eligible” is the month that the individual is

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 7 of H-1100

Replacing April 9, 2020

Revised/added text indicated by underscore Deleted text indicated by “”

determined to meet all the requirements for QMB eligibility.

Example:

If an individual applies for Medicaid on January 1 and is determined

to meet all of the requirements of eligibility at that time, even if the

state makes this determination on March 10

, the individual’s QMB

coverage would begin on February 1.

H-1121.7 Notice of Decision

Send the appropriate notice of decision to the

applicant(s)/beneficiary(s).

Note:

Applicants enrolled in Medicare Part A are not referred to the

Federally Facilitated Marketplace (FFM).