What does medicaid qualified medicare beneficiary mean

The Qualified Medicare Beneficiary (QMB) Program is a Medicare Savings Program that helps pay for Medicare Part A and Part B premiums, deductibles, and coinsurance.

Print-friendly Medicare Savings Program fact sheet, P-10062

You may be eligible for the Qualified Medicare Beneficiary Program if you:

• Are entitled to Medicare Part A.
• Have countable assets at or below the program limit*. If there is one person in your family, the asset limit is $8,400. If there are two people in your family, the asset limit is $12,600.
• Have countable monthly income* at or below 100% of the federal poverty level (FPL) after certain credits are applied. If there is one person in your family, the monthly income limit is $1,132.50. If there are two people in your family, the monthly income limit is $1,525.83.

Medicaid should already be paying your Medicare Part A and B costs (meaning you do not need to apply for Qualified Medicare Beneficiary Program benefits) if you receive Medicare and Medicaid and either of the following apply to you:

• You are enrolled in the Supplemental Security Income (SSI) program.
• You were enrolled in SSI but lost it for one of the following reasons:
  • You were getting Old Age Survivors Disability Insurance (OASDI).
  • You are the disabled adult child of parents who died or became disabled, causing you to get an increased or initial Social Security payment that made you unable to get SSI.
  • You are the disabled or elderly spouse of a person who died, causing you to get a Social Security benefit that made you unable to get SSI.

*The asset limits are effective January 1, 2022, and the income limits are effective February 1, 2022. The limits are based on federal guidelines, which may change each year.

If you are eligible for the Qualified Medicare Beneficiary Program, Medicaid will start paying for your Medicare Part A and B premiums, deductibles, and coinsurance the first day of the month after your application is approved.

When Medicaid starts paying your Medicare costs, your Social Security payment will increase, and you will get a notice from the Social Security Administration. The Social Security Administration will give you a refund for any payment you made after the date you were enrolled in the Qualified Medicare Beneficiary Program.

Even though you are enrolled in the Qualified Medicare Beneficiary Program in the month after your application is approved, your Social Security payment may not be increased for one to three months. This is the time that is needed for payments to be adjusted by Medicaid, Medicare, and the Social Security Administration. Getting a refund for those one to three months means your payments may be higher than usual for a short amount of time.

For example, if your application is approved in April, you are enrolled in Qualified Medicare Beneficiary Program in May. Your Social Security payment may not be increased until July. You will get a refund for premiums you paid for May and June.

Last Revised: June 15, 2022

Medicaid QMB, which stands for Qualified Medicare Beneficiary, is a program designed specifically for individuals that qualify for both Medicare and Medicaid coverage and that are financially unstable. This program provides these individuals with an alternative way to pay for their medical bills and can allow them to use Medicaid services to help cover the costs of their Medicare premiums and other associated costs of this insurance plan and all of the healthcare that they require and seek.

How Do You Qualify for Medicaid QMB?
This program mandates that individuals meet both the requirements for Medicare and Medicaid. Original Medicare is available to individuals 65 years of age or older and individuals with certain disabilities. Medicaid insurance caters to individuals with low income and provides an affordable, government-funded healthcare option for this demographic.

The QMB program has specific income requirements that must be met, and these amounts often change from year to year. In 2019,  the monthly income limits for individuals is $1,060 and the monthly income limit for a married couple is $1,430. There is also a limit on resources, which is set at $7,730 for individuals and $11,600 for married couples. Additionally, you must also be at or below the annual federal poverty level. The amounts of the QMB requirements and the poverty line generally coincide, but it is good to be aware of both.

In 2016, there were approximately 7.5 million individuals that are a part of the QMB program. In fact, nearly one out of every eight Medicare recipients was a member of this program. This number continues to grow and provides people with the opportunity to reduce their out-of-pocket healthcare costs, which can be highly beneficial when income is limited.

How Does the QMB Program Work?
The Qualified Medicare Beneficiary program works to help cover Medicare Part A and Part B premiums, as well as the costs of coinsurance, copayments, and deductibles. All of these costs can add up quickly, especially if you require a variety of different medical services.

This program is able to provide full payment of both the Part A and Part B premiums and the annual deductible costs of these plans as well as co-insurance costs and deductible amounts also covered in full. This means that you should not be billed for any approved care you receive under Medicare Part A or Part B that is received at a Medicare-approved facility by an approved provider. There should be no major exceptions to this other than the restrictions on care that Original Medicare puts in place.

Even if you are visiting a provider than does not accept Medicaid as an insurance, they still must comply with improper billing protections in place and cannot bill you directly. They must accept Medicare and QMB payment for their services and recognize this payment as being the full amount of the cost of service. Improper billing protections prevent individuals using the QMB program from being responsible for any cost-sharing expenses, no matter their origin.

It is important to note that if you are currently using a Medigap plan, the premiums associated with it are not covered by the QMB program. In addition, you should also be aware that states can impose laws specific to Medicaid, Medicare, and QMB programs. These laws may supersede national laws and may force individuals to provide a copayment with certain services. However, this fee should be quite small and Medicare and Medicaid services should cover the large majority of the cost.

If you are eligible for the Medicaid QMB program, you should apply for it to maximize your health benefits. This program provides a great deal of financial support for its enrollees and can make a major difference in the healthcare individuals receive.

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