The Qualified Medicare Beneficiary (QMB), Low Income Medicare Beneficiary (LMB), and Qualified Working Disabled (QWD) programs provide for coverage of Medicare premiums and/or cost sharing requirements based on the criteria established below.
Persons who are entitled to Medicare benefits under Part A (including those entitled by reason of enrollment in the premium-paying Part A program) or entitled to Medicare Part B-ID (see 2911) shall be eligible for restricted medical assistance without a spenddown if:
In addition to the above criteria, the individual must meet the general eligibility requirements of 2100. The individual does not have to be determined disabled to receive QMB coverage.
If approved for QMB, coverage becomes effective with the month following the month in which action is taken on the individual’s case. QMB coverage cannot begin prior to this month. If there is a break in assistance of one or more months, QMB eligibility may only be reestablished effective the month following the month in which action is taken. The following exceptions apply:
Individuals entitled to Medicare Part A may be eligible for QMB. Most individuals entitled to Social Security or Railroad Retirement benefits through their own account or through a spouse's or parent's account and who are age 65 or older or disabled for 24 months, automatically receive Part A coverage. Some individuals must actively apply for Part A coverage, including those with end-stage renal disease, certain disabled widows and widowers, and former federal, state, or local government employees whose employment became subject to the Medicare tax.
Individuals without sufficient work history may enroll in premium Part A at age 65. For example, individuals receiving SSI aged benefits may be eligible for premium Part A, while those receiving SSI disability benefits only would not.
Kansas is a group payer state, meaning individuals must have actual or conditional Part A enrollment before QMB eligibility can be established. Unlike in Part A buy-in states, enrollment in Part B alone is not sufficient to meet the Part A entitlement requirement for QMB.
QMB coverage may begin no earlier than the first month of Part A entitlement. Documentation of current Part A enrollment, the Part A start date, or documentation of conditional Part A enrollment must be obtained when applicable.
Individuals who are not currently enrolled in Part A but appear eligible and request QMB may have QMB eligibility initially determined if they apply for Part A within an allowable Medicare enrollment period (initial enrollment period, GEP, or special enrollment period.) If proof of conditional enrollment is provided, QMB coverage may begin the first day of the month following the month of Medicare enrollment, if otherwise eligible.
Individuals applying for QMB outside an allowable Medicare enrollment period must be denied until they can enroll in Part A and obtain an entitlement or conditional enrollment effective date.
Enrollment is Part A is not required in order to receive other forms of medical assistance; however, individuals seeking QMB coverage must enroll in Part A.
The income and resource methodologies of the Medically Needy program shall be applicable in determining eligibility with the exception of the 6 month base period rule and the allowable resource standards. Only the needs, income, and resources of the individual and his or her spouse or parent(s) shall be considered. Income, and resource methodologies are not applicable to active SSI recipients that are entitled to Medicare Part A, as they are deemed automatically eligible for QMB coverage on the basis of their SSI recipient status. (See 2671 above.)
Countable income shall be determined using the independent living disregards as specified in 7240. This would also apply to persons in LTC living arrangements. Only that person's income would be considered including the amount of any income the person is allocating to a community spouse or other family members in accordance with 8243 (4) or 8244.2. This allocation would not be deducted in determining countable income for QMB purposes. However, if an individual applies for QMB status who is receiving such allocation, the amount of that allowance must be considered in determining this person's eligibility.
Beginning January 1 of each year, the amount of any cost-of-living increase in Social Security benefits provided for that year shall be disregarded in determining QMB eligibility both for applicants and recipients until the new federal poverty level standards are put into effect.
The general resource guidelines of 5200 shall be applicable in determining countable resources. A transfer of resources under the spousal impoverishment provisions of 8144 and subsections would not be recognized in the QMB determination until the resource has been formally transferred.
A one-month base period shall be applicable to QMB determinations in accordance with 7330 (1). Total countable income to be considered in the eligibility base period shall be compared against the appropriate monthly standard see F-8, Kansas Medical Standards. Eligibility exists if the countable income does not exceed this level and resources are within allowable levels.
Eligibility for QMB coverage shall be determined separately for the qualifying individual except in instances in which there is more than one qualifying person in the family group.
In such instances, a single determination for all qualifying persons would be applicable. If the qualifying individual is a legally responsible person and the remaining family members request assistance (e.g., MA), his or her needs, income, and resources would also be included in that eligibility determination.
If the person's countable income exceeds the poverty level standard, there is no eligibility for QMB coverage. Persons who are not eligible for QMB may, however, be able to qualify for regular medical benefits based on a cash or spenddown determination.
Reserved
Medical coverage for QMB only eligibles is limited to payment of Medicare Part A and Part B premium, deductibles and co-insurance. This applies to Medicare covered services and items covered by Medicaid and those which are not covered by Medicaid. Because of this, it is necessary to complete a QMB determination on persons eligible for full Medicaid coverage. QMB eligibles are subject to Medicaid copay requirements, unless otherwise exempt. QMB coverage is designated on the medical identification card.
Persons who are entitled to Medicare benefits under Part A (including those entitled by reason of enrollment in the premium-paying Part A program) shall be eligible for coverage of Part B premiums only if:
Although the LMB program is, in essence, an extension of the QMB program, except for the fact that benefits are limited to Part B premiums only, persons qualifying for QMB are not also eligible for LMB. These are two distinct programs and do not overlap. Persons whose income does not exceed 100% of the federal poverty level qualify only for QMB benefits (see 2671). For LMB, the eligible person's income would need to fall between 100% and 135% of poverty.
The general guidelines regarding Part A eligibility and financial eligibility for the QMB program as specified in and are applicable to LMB. This includes the separate determination of eligibility as well as the disregard of the Social Security cost-of-living adjustment in the first calendar quarter. A one-month base shall be applicable to LMB determinations in accordance with 7330 (1). Total countable income to be considered in the eligibility base period shall be compared against the appropriate monthly poverty level standard (see F-8, Kansas Medical Standards). Eligibility exists if the countable income does not exceed this level, and resources are within the allowable level.
Eligibility for LMB coverage shall be established only in the MA and Medically Needy programs. Coverage allows for immediate buy-in of Medicare Part B premiums. LMB benefits can be provided for the month of application, future months and the prior eligibility period. There is no delayed effective date as with QMB. There are two different groups of eligible individuals that exists within the program as indicated below.
The regular LMB program is also known as the Specified Low-Income Medicare Beneficiary (SLIMB) program. Regular LMB is for those individuals with income between 100% and 120% of poverty. The Part B premium for this group is subject to normal Medicaid state/federal match. A person may qualify for LMB-only or for coverage of premiums while in spenddown status or in a prior eligibility period. Persons eligible for SI or Poverty Level programs do not receive any additional benefit from LMB and are, therefore, not eligible except for prior medical coverage. This is due to the fact that the LMB program covers only Part B premiums and such persons are already covered for Part B buy-in.
The Expanded LMB program is also known as the Qualifying Individual 1 (QI-1) program. Expanded LMB is for those individuals with income between 120 and 135% of poverty. The Part B premium for this group is subject to 100% federal funding based on federal law.
Persons are only eligible for Expanded LMB if they are not otherwise Medicaid eligible, or attempting to gain Medicaid eligibility. However, once established, an individual eligible for Expanded LMB can later seek full Medicaid if such a need arises. For example, if the individual applies for HCBS and is approved for services, Expanded LMB coverage should be closed as soon as possible given timely notice deadlines. Prior medical coverage may also be provided in these instances.
Reserved
Persons who qualify for Medicare benefits under the premium paying Part A program based on section 1818(a) of the Social Security Act shall be eligible for restricted medical assistance without a spenddown if:
In addition to the above criteria, the individual must meet the general eligibility requirements of 2100.
Medical coverage for QWD only eligibles shall be limited to the payment of Medicare Part A premiums. Coverage can begin as early as the first month of Part A enrollment.
Individuals are limited to QWD coverage only. If other coverage is sought, there is no eligibility for QWD.
Under section 1818(a) of the Social Security Act, persons who lose eligibility for regular OASDI disability benefits and Medicare because they are working and earning above the SGA level as described in 2634 can continue to receive Medicare coverage if they pay the applicable premiums. Such individuals will continue to meet disability criteria and must have qualified for Medicare prior to losing their cash benefits. They may enroll for either Part A and/or Part B coverage. However, under the QWD program, Medicaid coverage is only available for payment of the Part A premium. Only if the person qualifies for full Medicaid coverage based on meeting a spenddown would Part B premiums be covered.
A person must enroll in Medicare Part A to be eligible for QWD coverage. Eligibility would begin no earlier than the first month of Part A premium coverage. Documentation of their status under section 1818(a) and their Part A effective date will be required.
Persons who qualify for QWD will not be automatically enrolled and bought in to the Part A program. If they want Part A coverage, they would need to enroll for it on their own at the local SSA office. There is a 7-month initial enrollment period which begins with the month the person is notified concerning the loss of disability benefits. Part A premium coverage would begin in one of the following three months depending on when the person enrolls. If this initial period has passed, the person can normally only enroll during a general enrollment period which is limited to the months of January through March. Part A coverage would not begin until July 1 in these instances. There is also a special enrollment period connected with the premium Part A program for persons who did not enroll at their first opportunity because they were covered under an employer group health program. If that coverage ends, they have a 7-month period from the month the coverage ends to enroll for Part A. If the person applies for QWD outside of the permitted enrollment period, QWD eligibility would have to be denied until such time that the person can enroll for and begin receiving Part A benefits.
Part A premium coverage under section 1818(a), and therefore QWD eligibility, ends in the month the individual turns 65.
The income and resource methodologies of the Medically Needy program shall be applicable in determining eligibility with the exception of the 6-months base period rule and the allowable resource standards. Only the needs, income, and resources of the individual and his or her spouse or parent(s) shall be considered.
Countable income shall be determined using the independent living disregards as specified in 7240. This would also apply to persons in LTC living arrangements. Only that person's income would be considered including the amount of any income the person is allocating to a community spouse or other family members in accordance with 8243 (4) or 8244.2. This allocation would not be deducted in determining countable income for QWD purposes. However, if an individual applies for QWD status who is receiving such allocation, the amount of that allowance must be considered in determining that person's eligibility.
The general resource guidelines of 5200 shall be applicable in determining countable resources. A transfer of resources under the spousal impoverishment provisions of 8144, 8244 and subsections would not be recognized in the QWD determination until the resource has been formally transferred.
A 1-month base period shall be applicable to QWD-only determinations in accordance with 7330 (1). Total countable income to be considered in the eligibility base period shall be compared against the appropriate monthly 200% poverty level as referenced in the Kansas Medical Assistance Standards. Eligibility exists if the countable income does not exceed this level and resources are within allowable levels.
Eligibility for QWD coverage shall be determined separately for the qualifying individual except in instances in which there is more than one qualifying person in the family group. In such instance, a single determination for all qualifying persons would be applicable.
If the person's countable income exceeds the poverty level standard, there is no eligibility for QWD coverage. Persons who are not eligible for QWD may, however, be able to qualify for regular medical benefits based on a cash or spenddown determination.
Effective January 1, 2006, persons who are entitled to Medicare Part D are eligible for help with payment of Medicare Part D premiums, co-payment and deductibles if the requirements outlined in this section are met. See 2911.10 for Medicare Part D information.
Persons who are not entitled to Medicare Parts A and B are not entitled to Part D and, therefore, not eligible for the subsidy. Eligibility for the subsidy shall be determined regardless of the beneficiary’s enrollment status with a Part D plan. In order to realize the benefits of the subsidy, the individual must be enrolled in a Medicare Prescription Drug Plan, or designated alternative.
NOTE: Persons who are eligible for the Medicare Savings Program (MSP) coverage due to their Medicare Part B – ID (immunosuppressive drug) enrollment are not entitled to receive Medicare Part D, therefore, are not eligible for the Part D subsidy.
Although persons who are enrolled in an employer, union or group sponsored prescription drug plan which has been designated as a replacement for Medicare Part D [see 2911.10 (4) (e)] do not have to enroll in a Part D plan, such individual will generally not realize a benefit with a subsidy determination. The subsidy will only provide assistance with costs related to a plan through Medicare Part D, not through a retiree plan.
Persons determined eligible for the following types of medical assistance are deemed eligible for the Medicare Part D subsidy without a separate application:
An eligibility file is sent to CMS each month containing those individuals who meet the above criteria. The file is commonly known as the MMA file. Upon receipt of the monthly file, CMS confirms the individual is an eligible Medicare beneficiary and awards the subsidy. CMS will then communicate subsidy information to the Part D PDP.
NOTE: Persons receiving SSI benefits through Social Security, but not Medicaid, are also deemed eligible for the subsidy.
Both KDHE-DHCF and the Social Security Administration share responsibility for determining subsidy eligibility for all other applicants. While the Medicare beneficiary may apply with the entity of their choice to determine eligibility, an individual seeking subsidy coverage at KDHE-DHCF shall be directed to Social Security to file an application. However, eligibility staff may assist the individual in completing the SSA-1020 subsidy application form. The form should then be date stamped and mailed to the SSA processing center at:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1020
Wilkes-Barre, PA 18767-9910
Social Security will process the application and notify the applicant of the subsidy eligibility determination. An individual who has already applied for subsidy coverage with SSA should wait for that determination to be completed. However, the individual may file another SSA-1020 subsidy application with KDHE-DHCF while the original SSA application is still pending. The application shall be accepted, date stamped, and forwarded to SSA for processing.
For deemed eligibles, subsidy eligibility is effective with the first month of eligibility under one of the deemed groups above (including prior medical eligibility) and Medicare Part D entitlement. For individuals determined eligible, by the Social Security Administration (determined eligibles), subsidy coverage is effective no earlier than the month of application. Prior medical coverage is not applicable to Medicare Part D Subsidy determined eligibles.
Examples: Person 1 applies in May 2006 for LMB, including prior medical. He is approved effective February 1. Subsidy eligibility is effective February 1 with the LMB approval. Person 2 applies in May 2006 for subsidy only at the Social Security Administration and is approved. Subsidy coverage begins May 1, 2006 as there is no prior coverage.
To realize the benefit of the subsidy, the individual must enroll in Medicare Prescription Drug Plan (see 2911.10).
Those eligible for subsidy will receive benefits according to countable income, assets and deemed status. The eligible person receives assistance with Medicare cost sharing - premiums, deductibles and copayments. The level of premium assistance is limited and is equal to the lesser of the following: The monthly Part D premium for basic prescription drug coverage or the portion of the monthly Part D premium attributable to basic prescription drug coverage for a Part D plan that has an enhanced alternative coverage; or the greater of the low-income benchmark premium amount or the lowest monthly beneficiary premium for a prescription drug plan that offers basic prescription drug coverage. See the Kansas Medical Assistance Standards in the Appendix for the Medicare Part D benchmark premium amount.
No copayments apply to covered prescription drugs for those who are eligible for full Medicaid coverage and are a resident of an approved institutional living arrangement (nursing facility, state hospital, ICF-IID, swing bed hospital, head injury rehabilitation facility or other Medicaid approved institution) for at least 30 days, or who are enrolled in PACE.
When subsidy eligibility ends, the date actual coverage terminates depends on whether the individual was deemed or determined eligible.
Example 1: An individual files an application for medical assistance and is deemed eligible for subsidy coverage effective February 2011. In June 2011 the medical case is closed and the individual is no longer deemed eligible. Even though medical assistance has ended effective June 30, 2011, deemed subsidy coverage automatically extends through the end of December 2011.
Example 2: Same situation as in Example 1, except the medical case closes effective August 31, 2011. Since this individual was deemed eligible on or after July 2011, subsidy coverage automatically extends through the end of December 2012.
Example: An individual files an application with Social Security and is approved for subsidy coverage beginning in March 2011. Program eligibility requirements are no longer met in September 2011 and the case closes effective October 31, 2011. Determined subsidy coverage ends the date of program closure.
Example: An individual files an application with Social Security and is approved for determined subsidy with coverage level 3 beginning April 2011. The individual later files an application for QMB coverage and is approved beginning July 2011 with deemed subsidy coverage. Once the deemed record is received by CMS, the individual will have subsidy coverage from July 2011 through December 2012 at the QMB level.