Eligibility Online Manual

M1101 QMB

Purpose: This section will assist in determining whether an individual is eligible for Qualified Medicare Beneficiary (QMB).

Current Policy Effective Date: November 1, 2015

Date Last Reviewed: November 16, 2015

Previous Policy: December 1, 2011


1. Applicants Must Meet Basic Eligibility Factors

Refer to Section M600 for a description of all basic eligibility factors.

2. Applicants Must Be Entitled To Part A And Part B Medicare Insurance

3. Applicants Must Meet Income Requirements

Require the countable income to be within the maximum income standard of less than or equal to 100% FPL. Assistance unit size of two must not be exceeded. Refer to Medicaid Table 1. Refer to Section 905 for Income Disregards/Deductions.

4. Applicants Must Meet Resource Requirements

Require the countable resources to be within the resource limit for an individual, or couple. Refer to Medicaid Table 7 for the resource limit and Section M801 to determine if resources are countable.

5. Medicaid Will Pay Some Premiums And Deductions

Medicaid will pay Medicare Part A and B premiums.

Clients will receive a Medicaid card for the following limited services:

    • Yearly hospital and medical deductible.

    • Coinsurance payment.

In addition, clients may receive assistance with their Medicare Part D premium payments from the Centers for Medicare and Medicaid Services (CMS).

6. Clients May Not Receive Retroactive Medicaid

Do not authorize retroactive Medicaid for clients receiving QMB benefits, unless they are found eligible under another coverage group allowing retroactive medical assistance.

7 Benefits Begin On First Day of Month After Eligibility Determination

8. Clients Must Be Reviewed

Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.

Clients must be reviewed for other Medicaid program eligibility before closing cases.

9. Clients May Lose Benefits

The case will close on the first day of the next month when any of the following occur:

    • Client does not complete review.

    • Client enters a public institution.

    • Client dies.

    • Client determined no longer eligible.


Defining Group: Social Security Act §1902 (a) (10) (E)

Social Security Act §1905P

Income: 20CFR 416 Subpart K

Resources: 20CFR416 Subpart L

Clarifying Information:

1. QMB is defined as a beneficiary covered under the Medicare Catastrophic Coverage Act (MCCA) of 1988.

2. Resource Transfer Provisions Do Not Apply.

3. Compare total countable income to the single standard in Medicaid Table 1 when the income of the ineligible spouse is not deemed.

Worker Responsibilities:

Closing Cases

1. Finalize eligibility and close benefits in WES when the applicant is no longer eligible

2. Allow 15-day closure notice when an adverse action has occurred.