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What is the QMB program?

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Just the essentials...
  • The QMB or Qualified Medicare Beneficiary Program is a Medicare Savings Program.
  • Medicaid has four savings programs for eligible persons to save on Medicare costs
  • The Qualified Medicare Beneficiary Program can cover premiums, deductibles, copays, and coinsurance
  • Medicaid determines Medicare Savings Programs participation by income and need

The QMB is a Medicare Savings Program for low-income individuals and families that can save a lot of money. It is one of four Medicare Savings Programs. The QMB helps low-income Medicare beneficiaries pay Medicare Part A premiums, Medicare Part B premiums, and a significant amount of Medicare out-of-pocket costs including copays, deductibles, and coinsurance.

Comparison shopping is an excellent way to find the best values in private plans sponsored by Medicare and Medicaid. Costs are a significant factor in the usefulness of health insurance coverage. Comparison shopping can help find the lowest cost alternatives.

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Medicaid Boosts Medicare Beneficiaries

Medicaid offers savings programs designed to assist participants with low or no income. These programs help pay Medicare fees and costs so that the lack of resources does not prevent quality medical care as needed. The Medicare beneficiaries qualified for the QMB can also get Medicare Part D Extra Help.

Easy Ways to Apply

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Applicants should contact the local Social Security or Medicaid office in the state and county of residence. This is the easy way to apply. The forms are simple because it is an asset and income test. The income limit for the Qualified Medicare Beneficiary (QMB) Program is 100 percent of the federal poverty level.

The QMB helps pay Medicare Part A premiums, Medicare Part B premiums, Medicare deductibles, coinsurance, and co-payments. The 2015 asset or allowed financial resource limit was $7,280 for an adult individual or $10,930 for a married couple. The states usually exclude the values of the below-listed items.

  • Home or main residence
  • One personal automobile
  • Burial plot
  • Burial insurance or savings

Extra Help Goes a Long Way

Extra Help is a feature that provides payment assistance for prescription drugs. Extra Help can pay Part D premiums, a Part D plan’s prescription deductibles, and the costs of prescribed drugs. The beneficiaries that get QMB also get an automatic qualification for acceptance into the Part D Extra Help program.

Four Types of Medicare Savings Programs

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QMB and three other Medicare Savings Programs help low-income Medicare customers. They help pay expenses connected with Medicare medical services. In this way, Medicaid makes a small investment that can have positive patient outcomes.

When personal budgets prevent access to quality medical care, small problems can grow into severe illnesses or diseases. These savings programs can help pay persistent expenses in Medicare that can prevent members from getting the care they need.

Medicaid’s Low-Income Assistance Programs

Many individuals and families are dual eligible and get benefits from both major programs. The below-listed items are the four Medicaid programs to promote savings in Medicare services

  • Qualified Medicare Beneficiary
  • Specified Low-income Medicare Beneficiary Program
  • Qualifying Individual Program
  • Qualified Disabled and Working Individuals Program

The Medicare Savings Programs (MSPs)

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Medicare expenses have risen over the past twenty years as health care costs have risen across the country in in nearly every part of the industry. Medicare depends upon the private sector to provide health insurance and medical services. As price increases work through the private sector, they eventually cause Medicare prices to rise too.

The MSPs help break the pattern of increases. Combined with the Affordable Care Act, Medicare recipients have some tools to get more services and lower prices. The below-listed descriptions cover the basics of the Medicare Savings Programs.

  • The QMB Program is the Qualified Medicare Beneficiary program; Medicaid pays premiums for Part A and for Part B. It pays deductibles, coinsurance, and copays for Part B. The program accepts applicants with incomes as high as 100 percent of the federal poverty guideline.
  • The QDWI Program is the qualified disabled and working individuals program; it is a Medicare Assistance program for low or limited income persons. To be eligible, one must have income that is at or under the 200 percent mark of the federal poverty guideline. The primary benefit of the QDWI program is that it pays Medicare Part A premiums. In 2016, the Medicare Part A premium was approximately $450.00 per month.
  • SLMB is the Specified Low-income Medicare Beneficiary program. The program accepts Medicare participants with incomes in the range of 100 percent -120 percent of the federal poverty guideline. The SLIMB program can pay Part B premiums. For most subscribers, Part B premiums were about $105.00 per month or higher depending on income and late fees. This is the program’s primary benefit, and it is a significant part of the costs of Part B.
  • The Qualifying Individual Program can help recipients with incomes in the range of 120 to 135 percent of the federal poverty line. The QI savings program pays Medicare Part B premiums that range from $104.00 per month and upwards depending on fines and income.

Qualified Disabled and Working Individuals Program

The Social Security Administration advises disabled worker that have returned to work of a potential valuable benefit. They may be able to buy-in to Medicare Part A again. Some disabled recipients lose free Medicare Part A coverage when they return to work.

For some of these disabled workers, it may be possible to get assistance that pays the Part A premium. The approved income level can be as high as 200 percent of the federal poverty level.

Restrictions on the QDWI

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Medicaid reviews applications for the QDWI by resources and income. The 2016 resource limit was $4,000.00 for an individual and $6,000 for a married couple. These asset limits include bank accounts, savings accounts, bonds, stocks, investment securities, and some insurance.

The age limit is 64, and the applicant must no longer have had premium-free Medicare Part A upon return to work. The disabled worker must also rate as ineligible for Medicaid and the state medical assistance program. The QDWI can help disabled workers that have returned to work. One must contact the Medicaid office in the state and county of residence to pursue this valuable benefit.

QMB Pays Premiums

The QMB covers costs associated with Original Medicare and Part D Prescription Drugs. The QMB can pay Medicare Part A premiums. For those that purchase Medicare Part A, this is a substantial monthly expense.

The QMB can pay Medicare Part B Premiums. Without late enrollment fees, Part B premiums average about $105.00 per month. The QMB can pay Part D Prescription Drug plan premiums for certain plans.

QMB Pays Expenses

The QMB Program can pay Medicare out of pocket and other expenses. It can pay deductibles that can total more than $1,200 per year for Part A and more than $166.00 for Part B. The QMB can also pay copays that apply to services used by participants. The overall amount of these payments depends on upon the services used. The program can pay coinsurance required for many services.

In Medicare Part B, there is a common relationship of 80 percent coverage by Medicare and 20 percent by the client. The QMB program can pay part of the prescription drug costs for participants in a Medicare Part D: Prescription Drugs plan.

The QMB is an important Medicare Feature

The Qualified Medicare Beneficiary program can change the experience of participants and provide substantial relief from persistent costs. The annual Medicare cycle includes a deductible which was approximately $1,288.00 in 2016. Coinsurance and copays can build into the thousands very easily given even a short hospital stay and outpatient follow-up.

2016 QMB Income and Assets Summary

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The income for individuals was $1,010 per month or less. For couples, the combined limit was $1,355.00 per month. The resource limits were $7,280 for an individual and $10,390 for a couple. The program helped pay for Part A premiums which could be as high as $450 per month; Part B premiums that average $105 per month, and expenses.

The expenses include deductibles, copays, and coinsurance. Based on individual or family usage of medical services and benefits.

Eligibility for QMB

The keys are participation in Medicare Part A and income in the range of the federal poverty guideline. Applicants must be Medicare beneficiaries. The income must be in the range of the federal poverty guideline as adjusted by the review standards.

The states indicate the types of income and assets countable towards the limit and the limits for income, cash, and assets. States have similar programs for prescription drug benefits. The States determine eligibility for the QMB. They use particular state standards and practices. As a general pattern, the states require the below-listed items.

  • Applicant must be a Medicare Beneficiary
  • Enrolled in Medicare Part A
  • Reside in the state where the applicant makes the request
  • Have limited income and financial assets

The Federal Poverty Level

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The federal government sets an income standard each year called the federal poverty level. It is the official reference for determining eligibility for benefits and programs based on an individual or family’s annual income.

Set by annual income and number of household members, there is a large difference between states that either did or did not expand Medicaid. Because the FPL changes each year, applicants for the QMB will have a different limit each year. Unsuccessful applicants in a given year may later succeed as the FPL goes up.

The States set the QMB Standards

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The exact eligibility varies from state to state; the states set the rules and make the decisions. The financial resources must not be too large nor must the income be too high to qualify for QMB. Assets are typically bank accounts for checking and savings, investments that include stocks and securities. Some insurance might have a cash value that a State might count against the limit.

In 2016, the limits were $1,010 for an individual income and $ 1,355 for a couple. The rewards are substantial given the price of Part B premiums. The states specify the exact assets that they count and the upper limits for the below-stated categories.

  • Cash
  • Current income
  • Prepaid burial plot
  • Personal items
  • Savings
  • Investments( stocks, bonds, Certificates of ownership)

Getting the Good News

Approval for QMB is great news for the beneficiary, and it means that some bills will be paid on their behalf. Approvals give the precise dates that they take effect. The rules permit up to three months back coverage. For example, some recipients get reimbursed for three months of Part B premiums; drug coverage goes with the approval.

Review is not Predictable

After reviewing the list of assets countable by your state of residence, many applicants conclude that they do not qualify and they do not apply. This is a bad outcome because the state governments have freedom to adjust the income and assets that they consider.

For some states, they use policies that favor inclusion and will decide close issues in the applicant’s favor. They can disregard a certain portion of income such as that committed to insurance premiums. They can account for other assets in slightly different ways than suggested in official lists and notices. Information is critical and applying is the only way to find out.

The QMB is a Valuable Savings Program

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For those that qualify, the QMB is a valuable costs savings program for Medicare participants. It holds a potential to save significant amounts and particularly for those that use a moderate to heavy amount of services.

With relief aimed at persistent costs like deductible, copays, and coinsurance, Original Medicare subscribers can have a lot of relief from costs and expenses. With payment of annual Part A, B, and D premiums, the costs of Medicare would decline substantially for nearly any user.

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MULTIPLAN_GHHK5LLEN_Accepted Last Updated 3/18/2018