Qualified MediCare Beneficiaries (QMB) & Other Dual Eligibles

Medicare Savings for You

If you are entitled to Medicare and have a low income, your State may pay some or all of your Medicare expenses.

State Medicaid programs pay Medicare costs for certain elderly and disabled persons with low incomes and very limited assets. What this means is that, depending on your income and the value of things you own, you will not have to pay some or all of your out-of-pocket expenses for hospital, physician, and other services covered by Medicare. You could save hundreds if not thousands of dollars each year.

Several Programs Offer Help

There are several programs to help people pay their Medicare expenses: The Qualified Medicare Beneficiary or QMB program; the Specified Low-income Medicare Beneficiary or SLMB program; and the Qualifying Individual or QI program.

The QMB program is for persons with limited resources whose incomes are at or below the national poverty level. It covers the cost of the Medicare premiums, deductibles, and coinsurance that Medicare beneficiaries normally pay out of their own pockets. If you qualify for assistance under the QMB program, you will not have to pay:

  • Medicare's hospital deductible which is $764 per benefit period in 1998. The daily coinsurance charges for extended hospital and skilled nursing facility stays. The Medicare Supplementary Medical Insurance (Part B) premium, which is $43.80 per month in 1998. The $100 annual Part B deductible.
  • The 20-percent coinsurance for services covered by Medicare Part B, depending on which doctor you see.

The State covers these Medicare cost-sharing amounts for you. You are only responsible for paying for the various medical supplies and services not covered by Medicare, such as routine physicals, dental care, hearing aids, and eyeglasses. And, if required by your State, you would also be liable for nominal cost-sharing amounts each time you go to the doctor or use other benefits that require copayments.

While the QMB program helps those whose income is at or below the national poverty level, the SLMB program is for persons whose incomes are slightly higher than the poverty level, but not more than 20 percent higher. If you qualify for assistance under the SLMB program, you will not have to pay:

  • The $43.80 monthly Part B premium.

The State will pay the premium for you. You will, however, continue to be responsible for Medicare's deductibles, coinsurance, and for charges for health care services and medical supplies not covered by Medicare.

How Do I Qualify?

The rules may vary from State to State but, in general terms, to qualify for assistance under the QMB program, you must meet the following requirements:

  1. You must be entitled to Medicare Part A. If you do not have Part A or do not know whether you are entitled to Part A, check with any Social Security Administration office or call 1-800-772-1213.
    Most people are entitled to Part A based on their own employment or the employment of a spouse. Even if you or your spouse did not work or did not work long enough to entitle you to Part A, your State may buy it for you.
    If you are under 65, you can get Part A if you are on kidney dialysis or have undergone a kidney transplant. You can also get Part A if you have received disability benefits from either the Social Security Administration or the Railroad Retirement Board for more than 24 months. Your financial resources such as bank accounts, stocks, and bonds cannot exceed $4,000 for one person or $6,000 for a couple. Some things - like the home you live in, one automobile, burial plots, home furnishings, personal jewelry, and life insurance - usually do not count as resources.
  2. Your income must be at or below the national poverty level. The QMB monthly income limits in 1998 are listed below and include a $20 income disregard:

All States except Alaska and Hawaii

$691 (individual) $925 (couple) Alaska $860 (individual) $1,151 (couple) Hawaii $792 (individual) $1,060 (couple) Income includes, but is not limited to, Social Security benefits, pensions and wages. Interest payment and dividends can also count as income.

What If My Income Is Slightly Higher Than the Poverty Level?

If you do not qualify for QMB assistance because your income is too high, you may be able to get help under the SLMB or QI program. To qualify for SLMB assistance, you must meet requirements in number 1 and 2 listed under the previous section.

Also, your income cannot exceed the national poverty level by more than 20 percent. This means that in 1998 the SLMB monthly income limits (including a $20 income disregard) are:

All States except Alaska and Hawaii $825 (individual) $1,105 (couple) Alaska $1,027 (individual) $1,377 (couple) Hawaii $946 (individual) $1,268 (couple)

If you do not qualify for SLMB assistance because your income is too high, you may be able to get help under the QI program. To qualify for QI assistance, you must meet requirements in number 1 and 2 listed under the QMB section and not be otherwise eligible for Medicaid benefits. You will be responsible for Medicare's deductible, coinsurance and other related charges.

Also, your income cannot exceed the national poverty level by more than 35 percent for the State to pay your Medicare Part B premium. This means that in 1998 the QI-1 monthly income limits (including a $20 income disregard) are:

All States except Alaska and Hawaii $926 (individual) $1,241 (couple) Alaska $1,153 (individual) $1,547 (couple) Hawaii $1,062 (individual) $1,424 (couple). If your income exceeds the 35 percent limit but is less than 75 percent of the national poverty level, the State may pay part of your Medicare Part B premium. This means that in 1998 the QI-2 monthly income limits (including a $20 income disregard) are:

All States except Alaska and Hawaii $1,194 (individual) $1,603 (couple) Alaska $1,489 (individual) $1,999 (couple) Hawaii $1,371 (individual) $1,840 (couple)

Where Do I Apply?

If you already have Medicare Part A and think you qualify for either QMB, SLMB or QI assistance, you must file an application for Medicaid at a State, county, or local medical assistance office - not a Federal office. You can get the telephone number for your medical assistance office by looking under the "Toll-Free 800 Numbers" (cms.hhs.gov/medicaid/mcontact.htm)

What If I'm Not Covered By Medicare Part A?

If you are age 65 or older and think you qualify for this assistance but do not have Medicare Part A, you should first contact a Social Security Administration office. You may need to file an application for Medicare Part A. The telephone number and address for the nearest Social Security Administration office can be found in the telephone book. If you need help in getting this information, call 1-800-772-1213.

What Do I Ask For?

When you contact your medical assistance office, ask about the QMB, SLMB or QI program or the "Medicare Buy-In" program. Explain that you think you qualify for help in paying your Medicare costs and you want to know when and where you can file an application for Medicaid.

What Should I Bring With Me?

When you file an application for Medicaid, be prepared to answer questions about your income, property you own, and other assets. You will be expected to have copies of documents like bank statements, property deeds, and insurance policies to show the amount of cash you have and the value of things you own.

Verification of your enrollment in Medicare Part A and of your income and assets will be important in determining your eligibility for assistance. As your application is processed, you may be required to go through a face-to-face interview with a Medicaid caseworker.

If Your Application Is Denied

If your application for assistance under either the QMB, SLMB or QI program is denied, you have a right to appeal within 30 days of the denial. To file an appeal, go to or call the place where you filed your Medicaid application. You are guaranteed a hearing.

If you need assistance or advice, you may want to contact your State agency on aging. Assistance also may be available from the Legal Aid or Legal Services office in your State. These offices provide free legal services to people whose incomes are within certain guidelines.

The telephone numbers for all State offices can be found in the telephone directory under "State Government."

For More Information About Medicare

For more information about the Medicare program, please refer to The Medicare Handbook. Copies are available from any Social Security Administration office.


http://www.socialworkers.org/practice/aging/qmb.asp
12/19/2014
National Association of Social Workers, 750 First Street, NE • Suite 700, Washington, DC 20002
©2014 National Association of Social Workers. All Rights Reserved.
  • Update Your Profile in the Member Center
  • Login