Qualified Medicare Beneficiary (QMB) Program

The QMB Program requires the 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 Parts A and B,
Be enrolled in Medicare Part B,
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 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 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 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 the QMB program is approved.

QMB 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.

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.

Medicare Enrollment

Medi-Cal applicants and members must be enrolled in Medicare Part B before the can be evaluated for the QMB program. If the individual does not have Medicare Part A when they apply, QMB eligiblity must be granted if they meet all other eligibility criteria. Following the approval for QMB, DHCS will automatically enroll them into Medicare Part A and pay the Part A premium effective the first month of QMB eligibility through California's Medicare Part A agreement. Medicare Part A can be established at any time of the year for this population regarldess of enrollment periods. For example if the individual becomes eligible for the QMB program in January 2025, Medicare Part A enrollment and buy-in will also begin in January 2025.

For individuals approved for QMB but not yet enrolled in Medicare Part A, EWs should enter the first month of QMB eligibility as the Part A approval date. Previous conditional Medicare Part A requirements no longer apply when determining eligibility for the QMB program.

Verification of Medicare

The receipt of Medicare Part B benefits must be verified. Verification includes any of the following:

The Medicare card,
An SSA Medicare Award Letter,
A printout of the MEDS [Buy-In Bendex Information] INQB screen showing Part B enrollment.
Other correspondence from SSA, or
Verification from IEVS (Applicant System).

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 unclear if the member is eligible for Medicare Parts A and B, or
It is unclear if they are enrolled in Medicare Part B.

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, and issue benefits and the appropriate notices of action.

Approvals

A QMB Approval NOA must be issued when:

A person is eligible for Medi-Cal and QMB,
A person is approved for QMB only.
- Note: Send the appropriate denial for regular Medi-Cal benefits.

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, not a resident, etc.)
A person is found to be ineligible for Medicare Part A.

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 cases follow current eICT procedures.

SSI QMBs

Beginning January 1, 2025, DHCS will automatically enroll all SSI/SSP members into the QMB program, assign the QMB aid code (80), in MEDS, and send a NOA upon enrollment. All SSI/QMB cases will be managed directly by DHCS. The county will no longer grant QMB for SSI members in CalSAWS after January 1, 2025. If an SSI individual applies for QMB with the county, the application should be denied as "aided on another case".

For SSI/QMB individuals, the county shall continue to:

Assist with mailing out replacement BICs for SSI members,
Answer general questions,
Refer SSI members to contact the DHCS Medi-Cal Helpline at 1-800-541-5555 for questions about the QMB program.