Qualified Medicare Beneficiary (QMB) Program

The QMB Program requires State to pay the Medicare premiums, deductibles and coinsurance of low income Qualified Medicare Beneficiaries.

Note: Coinsurance is the amount Medicare charges the patient. It is based on the Medicare approved rate for a medical service.

General Eligibility Criteria

To be eligible as a QMB, a person must:

• Be eligible for Medicare Part A, hospital insurance.
• Be within the property limit.
• Have income at or below 100% of the Federal Poverty Level (FPL).
• Be a citizen or a Non-citizen who would otherwise be entitled to full-scope benefits if he/she were applying for regular Medi-Cal.

  • Note: An undocumented Non-citizen or an amnesty Non-citizen who would only get restricted Medi-Cal benefits is not eligible for QMB.

• Be otherwise eligible for Medi-Cal (for example, meet California residency and verification requirements).

  • Note: Application or eligibility for MC is not required to qualify and be eligible for QMB.

Two Basic Groups of QMBs

There are two basic groups of QMB eligibles; “QMB Only” recipients and “Dual Eligibles”. The description of each group and the benefits received are described in the following chart:

Applicant Type	Medi‐Cal Benefits	Advantages
QMB Only
Aged, blind or disabled (ABD) individuals who: Are not eligible for full-scope Medi-Cal due to excess property, or Are eligible for full-scope Medi-Cal but choose to apply for only QMB.	Receive a MC BIC. POS Device message will indicate that MC coverage is only for MEDICARE DEDUCTIBLES AND COINSURANCE”. Covers Medicare: Premiums (Part B for all QMBs and Part A for those who do not already get Part A free.) Deductibles. Coinsurance, based on Medicare approved rate.	Higher property limits. NOTE: EWs should encourage full-scope Medi-Cal whenever possible, as regular Medi-Cal covers more than QMB, including: Medicare Part B premium (thru Buy-In), Medicare deductibles and coinsurance. Additional medical services; including, but not limited, to: Outpatient prescriptions and eye glasses. Custodial and skilled nursing facility level of care.
Dual Eligible QMBs
Qualify for full MC, Medicare Part A, and have income at or below the QMB income limit, including: Some ABD-MN individuals. SSI/SSP recipients with or without “free” Part A. Certain IHSS or CalWORKs recipients.	Receive their regular MC; however, the QMB aid code is reported to MEDS and can be viewed on one of the Special Program Screens. POS Device Message (on MOPI MEDS screen): “...1st SPECIAL AID CODE: 80 PART A, B... PART A, B AND D MEDICARE COVERAGE W /MEDICARE ID #     MEDICARE PART A AND B COVERED SVCS MUST BE BILLED TO MEDICARE BEFORE BILLING MC...”	The state receives federal funding for Buy-In. Once enrolled in Medicare Part A, individuals have a slightly wider choice of hospitals and nursing homes. Medi-Cal pays the Part A premium for those individuals who do not receive it free.

 When to Evaluate for QMB

EWs must evaluate QMB eligibility when:

• An applicant is applying for QMB.
• A Medi-Cal applicant is aged, blind or disabled and has Medicare (or is potentially eligible for Part A).
• An SSI/SSP recipient applies for QMB and has Part B Medicare and no Part A; or, pays a premium for Part A.
• An SSI/SSP recipient who already has Part A free.
• An aged, blind or disabled Medicare eligible person is included in a CalWORKs cash household or is applying for IHSS.
• A redetermination is due.
• A person is eligible for Medicare Part A and there is a change in income or a change in the QMB income limits.

Effective Date of Eligibility

There is no retroactive eligibility for QMB. Aid code ‘80’ displays on one of the Special Program Segment in MEDS once QMB program is approved.

For those applicants/recipients that already have Medicare Part A, eligibility begins the first of the month following the date that the EW actually determines and authorizes QMB eligibility in CalSAWS.

Note: This requirement is due to the State Buy-In agreement with the Social Security Administration.

QMB Examples

Example 1: QMB OnlyExample 1: QMB OnlyA customer applies for QMB January 15. The EW processes the application and clears eligibility on February 8. The effective date of QMB eligibility is March 1. However, it will take 2-3 months for Buy-In to take place. Once Buy-In is activated, the customer will be reimbursed for the Medicare Part A and/or Part B premium back to March.

Example 2: Dually EligibleExample 2: Dually EligibleA customer applies for Medi-Cal January 31. The EW determines on 3/2 that there is Medi-Cal eligibility effective January 1 and that the client is under the QMB income limit. QMB eligibility begins April 1. 

Example 3: Approved Month Following the ApplicationExample 3: Approved Month Following the ApplicationThe customer applies and clears eligibility in March, but does not approve the case until 4/15. QMB eligibility begins April 1, as the EW cleared eligibility in March.

Pre-Approved QMBs

Individuals who meet QMB eligibility criteria, but who must apply for Medicare Part A during the “general enrollment period” from January to March each year (because they did not apply during their “initial enrollment period”), are “pre-approved QMBs”. Their QMB benefits will actually begin in July 1. Effective January 1, 2023, Individuals applying for QMB can apply at any time of the year, and their Medicare enrollment will start the month following the application month for Medicare.

For “pre-appoved QMBs” with conditional Medicare part A (PAYOR status ‘Z99’ on INQB MEDS screen) cases, EWs should use the MC application date as the Part A Approval Date.

ExampleExample

Ineligible QMBs

Individuals applying between April and December who do NOT have Medicare Part A, must be referred to SSA to apply for conditional Part A. If SSA does not allow them to apply for conditional Part A, deny the application.

Note: If they appear to meet the other QMB criteria, advise them to apply for conditional Part A at SSA during the next general enrollment period (January-March), and reapply for QMB.

Verification of Medicare Part A

Medicare Part A benefits must be verified. Verification includes any of the following:

• The Medicare card (“Hospital insurance” indicates Part A coverage).
• An SSA Medicare Award Letter.
• A print of the MEDS [Buy-In Bendex Information] INQB screen showing Part A entitlement.
• Other correspondence from SSA.
• Verification from IEVS (Applicant System).

“Conditional” Medicare Part A

Those individuals who are not receiving Part A but who would be eligible for it by paying a premium may sign up for “conditional” Part A Medicare.

• This means the client is requesting Part A Medicare only if the state pays the premium. They will not be charged a premium if ineligible for QMB.
• Conditional enrollment must take place between January 1 and March 31, or during the individual's initial enrollment period when he/she first becomes entitled to Medicare.

MC 176 QMB-3

QMB applicants are to be referred to their local Social Security Administration office with a “Qualified Medicare Beneficiary (QMB) Referral” (MC 176 QMB-3) when:

• It is necessary to apply for conditional Medicare Part A, or
• They state that they have Medicare Part A or that they think they are eligible for it, however they do not have any verification.

Note: Social Security uses the “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SCD 176 QMB) in the SSI QMB Mail-In Referral procedure. This procedure allows Social Security to refer by mail all SSI/SSP recipients who are “conditionally” eligible for Medicare Part A to Social Services to apply for QMB.

QMB applications must be recorded according to the information provided on the MC 176 QMB-3 or other verification from the Social Security Administration as follows:

If...	Then...
The QMB applicant is conditionally eligible for Medicare Part A (is applying for Part A during the general enrollment period)	Approve QMB. Benefits wi Benefits will begin following the application month for Medicare.  Follow up immediately to ensure that: A MEDS QMB record has been established on one of the Special Program Segment [INQ1], [INQ2], or [INQ3] screen and A pending accretion [STATUS] code is showing on the Buy-In and Bendex Information [INQB] screen. Follow up in August to verify Medicare approval and: Follow up to verify Medicare approval and: Review the MEDS [INQM] and [INQB] screens to determine if the Buy-In accretion was successful. Take corrective action if Buy-In rejection occurs.
The QMB applicant is eligible for Medicare Part A	Approve QMB. Eligibility is effective whichever of the following dates is later: The Medicare Part A effective date, or The first of the month following the date the EW determines QMB eligibility.
The QMB applicant is not eligible for Medicare Part A or must reapply during the general enrollment period	Deny/discontinue QMB.

QMB Property Determination

The net non-exempt property of a QMB applicant/recipient prior to 1/1/2010 cannot exceed twice the Medi-Cal property limit. As of 1/1/2010 the property limit is three times the Supplemental Security Income property limit, plus an annual percentage increase equal to the increase in Consumer Price Index (CPI).

Note: The QMB property rules contained in this section also apply to the Specified Low-Income Medicare Beneficiary (SLMB) Program and the Qualifying Individual (QI-1) Program.

The “QMB/SLMB Property Worksheet, Adult” (MC 176P QMB/SLMB-A) is used (optional) when determining eligibility for the QMB/SLMB/QI Only programs.

If the QMB applicant/recipient is eligible for Medi-Cal from another program (e.g., ABD-MN, SSI/SSP) the QMB property limit is met.

Rules

The EW must follow the rules below when determining QMB property eligibility for the following groups of people:

Individuals (Adults) with no Spouse (age 18 and over)

First determine property under Non-MAGI Medi-Cal rules. (MFBU rules apply.) The individual is dually eligible if equal to or under the Medi-Cal property limit.

If over the Non-MAGI Medi-Cal property limit, then the following apply:

• Count only the resources of the QMB/SLMB/QI applicant.
• Do not consider the property of other family members in the home.
• The applicant is QMB/SLMB/QI property eligible if equal to or under twice the Medi-Cal property limit for one.

Individuals Ages 18-21

A QMB/SLMB/QI applicant age 18-21 is considered an adult for a QMB (or SLMB) property determination, even though he/she would be treated as a child for Non-MAGI Medi-Cal (e.g., is a blind or disabled MN person who is living in the home of a parent and is currently in school).

• Determine property under Non-MAGI Medi-Cal rules if applying for Non-MAGI Medi-Cal. (MFBU rules apply.)
• For QMB/SLMB/QI, count only the resources of the 18-21 year old and his/her spouse, if any.

Couples, Both Spouses in Home

These rules apply whether one or both spouses are applying for QMB/SLMB/QI.

• A married person under age 18 is considered to be an adult for QMB/SLMB/QI.
• If only one spouse is receiving Medi-Cal from another program, the QMB/SLMB/QI property limit is met for both spouses.
• First determine property limit. (MFBU rules apply.) The individual (or couple) is dually eligible if their property is equal to or under the LIS property limit.

Child, Under 18

Rarely will a child under age 18 be eligible for QMB/SLMB/QI, as a child can only be eligible for Medicare if in need of maintenance kidney dialysis or a kidney transplant.

Contact the Medi-Cal Coordinator for instructions. The property determination is different from the instructions outlined above.

Other Requirements

QMB Only applicants/recipients must meet all other Medi-Cal Program requirements, including:

• Completion of all appropriate Medi-Cal forms (MC 13, Rights and Responsibilities, etc.)
• Providing any necessary verifications. (IEVS is required.)
• Completing an annual redetermination.
• Reporting any changes within 10 days. (Income reports are not required for ABD-MN households.)
• Maintaining California residency.

Notices of Action

EWs are required to determine the level of benefits each Medi-Cal applicant is entitled to, explain the options (including spenddown), and issue benefits and the appropriate notices of action.

Approvals

A QMB Approval NOA must be issued when:

• A person is eligible for QMB only.

  • Note: Send the appropriate denial for regular Medi-Cal benefits (e.g., excess property).

• A person is otherwise eligible for QMB and is “Preapproved” pending confirmation of eligibility for Medicare Part A.
• When an ABD-MN eligible person who is paying his/her own Medicare Part A premium is income eligible for QMB, and is therefore entitled to State Buy-In of the Part A premium.

A QMB Approval NOA must not be issued when an individual is dually eligible and receives Medicare Part A free. In this situation the client receives no additional benefits. However, the State will receive federal funding for Buy-In.

Denials/ Discontinuances NOA

Denial and discontinuance NOAs are automatically generated when the QMB budget computation determines that the client is not income eligible for QMB.

A QMB denial or discontinuance must be sent when:

• A person has applied for, or received, QMB Only and is found ineligible. (e.g., excess income, property, not a resident, etc.)
• A “pre-approved” person is found ineligible for Medicare Part A.
• An ABD-MN applicant/recipient is not eligible for Buy-In of his/her Part A premium payment due to excess income.

A QMB denial or discontinuance NOA is NOT required for dually eligible ABD-MN applicants/recipients who have free Medicare Part A coverage.

Erroneous Discontinuance

The QMB eligibility must be restored back to the date the QMB eligibility was erroneously discontinued. Although the QMB does not provide retroactive eligibility, eligibility can and must be reinstated for past months (there should not be any break in aid) when a client was eligible.

In order for QMB buy-in to be reinstated, the MC Buy-In unit must retroactively pay for all Medicare premiums in arrears to Social Security Administration. Once the QMB eligibility is restored on MEDS, the State’s Medicare Buy-In system will process a Medicare Part A buy-in transaction. In order to ensure that the Medi-Care buy-in transaction is processed correctly, the EW can submit an online State Medicare Buy-In Problem Form to DHCS, Medi-Care Buy-In unit.

ICTs

QMB Only

QMB Only cases follow current eICT procedures.

SSI QMBs

The EW in the old county will receive an alert (CWEA) when the SSI county of responsibility changes. Initiate an eICT to the new county when the MEDS alert is received.

SSI QMBs

SSI/SSP recipients have full Medi-Cal coverage. However, they may benefit from Buy-In of their Part A premium if they are QMB eligible and:

• They are paying a premium for their Medicare Part A benefits, or
• They don't have Medicare Part A because they cannot afford to pay the premium.

Medicare Part A benefits may provide them with a slightly wider choice of hospitals; otherwise, there is no benefit.

Application Forms

An SSI/SSP recipient has already been determined eligible for and is receiving MC. Therefore, when an SSI/SSP recipient applies for QMB, no new application is required.

SSI QMB Mail-In Referral Procedure

The following SSI QMB Mail-In Referral procedure has been established with the Santa Clara County Social Security Field Offices.

1. Social Security:  
   1. Completes an “SSI Eligible Only - Qualified Medicare Beneficiary (QMB) Referral” (SCD 176 QMB) for each SSI recipient applying for “conditional” Medicare Part A.
   2. Mails the SCD 176 QMB directly to the Assistance Application Center (AAC) as an application for QMB MC.
2. AAC Mail Room:  
   1. Forwards the SCD 176 QMB to Clerical.
3. Clerical:    
   1. Forwards the SCD 176 QMB as follows:
      1. If there is an active case record in any aid type, then the SC 176 QMB is sent to the supervisor of the current case carrying EW.
      2. If there is no active case record, then the SC 176 QMB is sent to the appropriate intake office.
4. Receiving District Office:
   1. Ensures that the application is ID’d and assigned timely.
5. EW:    
   1. Determines SSI QMB eligibility.
      1. Use the [INQX] MEDS screen to verify and determine income eligibility.
      2. Use the SCD 176 QMB as verification of “conditional” Medicare Part A.
         1. The SCD 176 QMB and copies of MEDS screens used to verify income and Medicare eligibility must be retained in the case file.
   2. Approves/Denies the QMB application and issue the appropriate approval/denial Notice of Action (NOA).
   3. If approved, completes the appropriate follow-up action.
      1. Ensures an active QMB record is established on one of the MEDS Special Program Segment [INQ1], [INQ2], or [INQ3] screen.
      2. Ensures Buy-In accretion is initiated (i.e. “61” in the [STATUS] field on the [INQB] MEDS screen).
      3. Ensures Buy-In accretion is later added to the Buy-In Program (i.e. “1161” in the [STATUS] field on the [INQB] MEDS screen). 

Phone/Walk-in Applications

SSI/SSP recipients who are not referred by Social Security to the county by mail with a SCD 176 QMB may apply for QMB by phone or in person.

Application Requirements

• A face-to-face interview is not required.
• A property determination is not required.
• An income determination is required.
• Verification of “conditional” Medicare Part A is required.
• An SSI QMB applicant must receive a QMB approval or denial NOA.

Income Determination

EWs must determine the SSI/SSP recipient's net non-exempt income. SSI/SSP income is exempt.

The [Title XVI-SSI/SSP Information] INQX MEDS screen can be used to verify countable income. Send the MEDS screen to IDM as an income verification.

• If the NET-UNEARN-INC, NET-EARNED-INC and DEEMED-INCOME are equal to or less than the QMB income limit for one, the person is QMB eligible.
• If the total countable income is over the QMB income limit for one, the person is ineligible for QMB.

If the information from the [Title XVI-SSI/SSP Information] INQX screen is not available, use other income verifications and complete the MC 176 QMB/SLMB 2A (or use MACB whenever possible).

Verification of Medicare Part A

The SSI/SSP recipient must verify that he/she has applied for “conditional” Medicare Part A.

• The SCD 176 QMB is used by Social Security to refer an SSI/SSP recipient to Social Services by mail to apply for QMB. This form serves as verification that the SSI/SSP recipient has applied for “conditional” Medicare Part A.
• The MC 176 QMB-3 is used to refer an SSI/SSP recipient who has filed an application for QMB, but has not yet filed an application for Medicare Part A to the Social Security Administration to apply for “conditional” Medicare Part A. This referral should only be done after QMB income eligibility is determined.
  • Mail the MC 176 QMB-3 to the recipient, or issue in person, during SSA's “general enrollment period”, January 1 through March 31. 

    • NOTE: Sometimes SSA extends the general enrollment period.

  • Deny the QMB application if SSA states that the person is not eligible for Medicare Part A or that he/she must wait until the next “general enrollment period” to apply.

The verification of Part A entitlement (SCD 176 QMB, MC 176 QMB-3 or print of [INQB] MEDS screen) must be filed in IDM.

Redetermination (RDs)

The EW must review MEDS to ensure that the individual is still receiving SSI. Once SSI eligibility is confirmed, only two requirements must be completed by the EW:

1. Reverify the SSI/SSP recipient's net non-exempt income via the [INQX] screen on MEDS.
2. Check the [INQ1], [INQ2], or [INQ3] and [INQB] MEDS screens to ensure that QMB eligibility is being correctly reported to MEDS and that verification of Medicare Part A entitlement is on file.

Deny or discontinue QMB if the individual is ineligible for Part A.

Copies of MEDS screens used to verify income and Medicare eligibility must be filed in IDM. No other forms or verifications are necessary for SSI QMB redeterminations.

Discrepancies

Occasionally the EW will receive information from an SSI QMB applicant which is inconsistent with SSI and/or QMB eligibility rules. Although the EW is not required to verify anything beyond income (as recorded on MEDS) and Medicare Part A entitlement, discrepancies in reported information must be resolved.

ExampleExampleWhile an SSI recipient is applying for QMB she tells the EW that she has $20,000 in savings. The EW is to deny QMB for excess property, advising the customer of the QMB property limit. Also, advise the customer that she is over the SSI property limit and that she is to report this information to the Social Security Administration. The EW is not required to contact Social Security and need not follow-up to see that the customer has done so.

Whereabouts Unknown Discontinuance

Prior to discontinuing an SSI QMB case due to returned mail, the EW must review the SSI MEDS record or contact the Social Security Administration via a “Referral of Applicant to SSA” (SCD 169) to determine if the beneficiary has reported a new address to Social Security. If this information is available, the EW must update in CalSAWS and the case must not be discontinued due to Whereabouts Unknown. If a new address is not available from MEDS and/or Social Security, the case must be discontinued due to Whereabouts Unknown.

Related Topics

Medicare Savings Programs (MSP)

Specified Low-Income Medicare Beneficiary (SLMB) Program

Qualifying Individual (QI-1) Program