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 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.

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

Mrs. Smith applied for “pre-appoved QMB” program on 03/24/2017 with a proof of Conditional Medicare part A approval that she applied in 02/2017 during open enrollment period at Social Security Administration. She met all other eligibility criteria and was approved for “pre-approved QMB” effective April 2017 in CalWIN and with ELIG-STAT ‘891’ on one of the special segments in MEDS. In July 2017, Medicare part A buy-in will be automatically initiated to trigger ELIG-STAT in MEDS updated from ‘891’ to ‘301’ that indicates Mrs. Smith’s QMB benefit will start on 07/01/2017.

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.

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.

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 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.