2143 Qualified Medicare Beneficiaries | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Qualified Medicare Beneficiaries

Effective Date:

November 2023

Chapter:

2100

Policy Number:

2143

Previous Policy Number(s):

MT 68

Updated or Reviewed in MT:

MT-71

Requirements

Qualified Medicare Beneficiaries (QMB) is a Q Track class of assistance (COA) that provides a Medicare supplement to individuals who meet financial criteria based on the Federal Poverty Level (FPL).

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.

Application for Other Benefits, 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.

No property search is required for this class of assistance.

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 GeorgiaCares on a simplified application form DCH 700, Medicare Savings for Individuals. (County DFCS shall also use this application form which is available from Central Supply.)

Special Considerations

Any applications that are sent to DCH will be forwarded to the appropriate County Departments. The application date is the date stamped as received by DCH.

Procedures

Follow the steps below to determine QMB eligibility.

Step 1

Accept the A/R’s QMB application.

A face-to-face contact and office interview is not required at initial application or annual redetermination.

Step 2

Contact the A/R by telephone only if information provided on the application is not sufficient to process the case.

Step 3

Verify Part A Medicare entitlement by one of the following:

client statement, if copy of card or other written verification is not provided or available
a RSDI Award Letter
BENDEX, SOLQ under Interfaces in Gateway
an MBR Query Card
notification from a local SSA office

Step 4

Determine all basic eligibility criteria except LOS, LOC and Application for Other Benefits. Accept A/R’s statement regarding residency. Refer to Chapter 2200, Basic Eligibility Criteria.

To fulfill the TPR requirement on a QMB applicant who reports a TPR, copy the application and send to the DCH TPL Unit. Attach a copy of the insurance card if available.

Step 5

Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting to determine the following:

whose income and resources to consider
which QMB income and resource limit (individual or couple) to use
which eligibility budget to complete

For all applications and annual redeterminations: The A/R’s statement of income and resources provided on the application/review form is acceptable verification.

No further verification is required unless questionable. Call, if needed, to confirm TPR status. If BENDEX/SDX/SOLQ or other information known to the agency indicates an amount different from the A/R’s statement and is determined to be current, use this amount over the A/R’s statement.

If a Medicare eligible couple both apply for a Q Track COA and they are income ineligible as a couple for all Q track COA, calculate their eligibility as individuals for income but jointly for resources and approve each under whichever Q track COA they are eligible.

The Social Security number of a spouse who is not applying for benefits is not required unless eligibility cannot be established without it.

Step 6

Approve QMB on the system to begin the month following the month of case disposition if the A/R meets all the above eligibility requirements. However, if approval of the case is not completed within the standard of promptness due to agency or other agency delay, use the QMB override feature to not penalize the A/R for any month(s) in which the individual meets all of the eligibility requirements in that month, as long as it is for a month after the month of application.

Step 7

Notify the A/R of the case disposition via the system generated notice.

Special Considerations

Processing a QMB Application on an SSI Recipient

Effective August 1991, SSI Only recipients must apply for and be approved for QMB before DCH will pay the Part A Medicare premium through the buy-in process.

The following SSI recipients must apply for QMB at DFCS in order to have the premium paid by DCH:

Aged SSI Only recipients who are enrolled in Part B only. These individuals are eligible for Part A Medicare with a monthly premium. SSI Only (without RSDI or RR income) recipients who are age 65 or older are eligible for Part A Medicare with a monthly premium. The member will not receive Part A until the QMB application is approved.
SSI recipients (SSI only) whose claim number ends with an “M”. This information can be confirmed by viewing electronic sources such as (SDX, Bendex and SOLQ).

The following SSI Only recipients will receive a letter from DCH informing them of the need to apply for QMB:

SSI applicants aged 65 or older who are newly approved by SSA to receive SSI
SSI recipients who reach age 65

The SSI Only recipient must submit an application for QMB through DFCS.

In October 2017, DCH issued a memorandum regarding SSI recipients eligible for Part B only (eligible for Medicare premium Part A). DFCS eligibility workers should accept and make an eligibility determination on an MSP application from any SSI-eligible individual, provided the individual is enrolled in Part A, Parts A and B, or Part B only. Although DCH pays the Medicare Part B premium for SSI-related Medicaid members when they become entitled, they must file an application with DFCS for QMB if they have a Medicare claim number that ends with “M" and wish to have the Part A Medicare premium paid by DCH.

Current SSI eligibility is prima facie evidence of financial eligibility for QMB. The SDX record showing current SSI pay status is acceptable verification. Document the case that the SDX screen has been viewed.

DFCS eligibility workers must enroll individuals in Medicare Part A buy-in after the QMB eligibility determination. Workers should not refer individuals to SSA to apply for Part A. Part B enrollment indicates they are eligible for Part A with a monthly premium.

Follow the steps below to establish QMB eligibility for an SSI Only and/or combo recipient.

Step 1

Step 2

Obtain information necessary to process the application. An interview is not required. Additional information may be obtained by contacting the applicant by telephone or mail.

Step 3

Document QMB financial eligibility based on receipt of SSI.

An SSI certification letter is acceptable verification if SDX is not available.

Step 4

Scan a copy of the letter referring the recipient to DFCS to apply for QMB Into current document imaging system.

Step 5

Verify potential Part A Medicare eligibility by one of the following:

the DCH letter to the A/R regarding QMB and Buy-In
the A/R’s DOB on SDX showing current age as 65 or older
“AI” at the end of the SSI claim letter
an SSI certification letter
SOLQ

If none of these methods of certification is available, request the A/R obtain a letter from SSA verifying potential eligibility for Part A Medicare entitlement.

Step 6

Approve QMB to begin the month following the month of case disposition if the A/R meets all above eligibility requirements.

Step 7

Notify the A/R of the case disposition via the system.

Reviews for SSI Recipients

Redetermine eligibility in the month due by means of a telephone contact with the client and review of SDX to show that the client remains in current SSI pay status. Since A/R is SSI eligible, no further forms or contact is required.

QMB Recipient under Medicare SNF Care

If the QMB recipient qualifies for Medicare Skilled Nursing Facility (SNF) care, Medicaid is required to pay the copayments even if that amount is zero. QMB individuals are not required to apply for Nursing Home Medicaid if they do not desire to do so. (Note: after the first 100 days in a benefit period QMB recipients will be responsible for all cost.)

When a QMB recipient is admitted to a nursing facility under Medicare SNF care, the nursing facility will complete a Form DMA-59, Sections I, II, and III and email form to dma-59.forms@dch.ga.gov. The nursing facility will notify DCH when the individual is discharged from Medicare SNF care by completing Section IV of the same Form DMA-59 and emailing the form to dma-59.forms@dch.ga.gov.

If an individual is already eligible for QMB or SLMB and later applies for, and is eligible for, a full Medicaid aid category, such as SSI, Nursing Home or Waivered Services, the MSP program should remain open. The individual is dually eligible.