The Qualified Medicare Beneficiary (QMB) program became effective in Missouri on July 1, 1989.
The purpose of the QMB program is to assist certain individuals by paying their Medicare premiums and by making payments to their medical providers for the coinsurance and deductibles for Medicare services.
The legal basis for the administration of this program is Section 1905(p) of the Social Security Act, and Section 208.153 (RSMo). The determination of eligibility for individuals in this program is outlined in 13 CSR 40-2.270.
There are three general eligibility requirements for the QMB program. To be eligible for the program, an individual must:
QMB Resource Maximums:
|January 1, 2009||$4,000||$6,000|
|January 1, 2010||$6,600||$9,910|
|January 1, 2011||$6,680||$10,020|
|January 1, 2012||$6,940||$10,410|
|January 1, 2013||$7,080||$10,620|
|January 1, 2014||$7,160||$10,750|
|January 1, 2015||$7,280||$10,930|
|January 1, 2017||$7,390||$11,090|
|January 1, 2018||$7,560||$11,340|
|January 1, 2019||See Appendix J|
Additionally, the QMB applicant must also meet the MHABD general eligibility requirements of:
The individual MUST be enrolled in Part A Medicare in order to be eligible for QMB. (Applicants can be conditionally enrolled in Part A; see below for discussion). Further, QMB coverage cannot begin until the Part A Medicare entitlement date (the date the Part A coverage actually begins, regardless of when enrolled).
"Part A" is the name given to the Hospital Insurance coverage provided by the Medicare program. Part A differs from Part B, or Supplemental Medical Insurance, (SMI) in basic coverage, and claimants may have one or the other, or both. This coverage can be automatic, with no charge to the insured or it may require an application for coverage, with or without a premium payment.
Verify Part A through the IIVE process. Make an entry in the HIR field to assure receipt of Hospital Insurance entitlement information on the IIVE printout. The IIVE printout shows both Medicare Part A and Part B entitlement with effective dates, under the heading "Medicare Data". Part A is shown as "Hospital Insurance". Use this information as verification of Part A entitlement. A Medicare card, in itself, does not verify current Part A coverage.
If the claimant has provided a Medicare card and the IIVE response printout does not show Medicare eligibility, DO NOT DENY QMB ELIGIBILITY solely on this basis. Recheck the number from the card with the entries on the IIVE inquiry. If the card and the entries on the IIVE response agree, complete an IM-76 to send to the Social Security office requesting Medicare information. If this procedure does not resolve the discrepancy, allow the claimant an opportunity to provide further verification of current Medicare Part A eligibility.
The following paragraphs explain who is eligible to receive Part A Medicare, and how it can be obtained. This information is for the use of the worker only and should not be used to determine eligibility.
Persons may enroll in Medicare when they become 65. Enrollment can occur in the 3 months prior to, the 3 months following, and the month of their 65th birthday. Beginning dates of coverage for this enrollment vary with date of enrollment. If claimants miss this enrollment period, they can enroll during the open enrollment period which is held each year from January 1 through March 31, with coverage beginning July 1 of that year.
For individuals who are 65 years of age and over and receive a cash benefit (SSA or RR), or persons receiving disability benefits for at least 25 months, Part A Medicare coverage is automatic and free.
Some individuals are eligible to receive free Part A Medicare, but must make an application to enroll. This includes anyone that is 65 and over, and insured but not receiving a benefit (SSA or RR), any insured government workers 65 and over, and SSA eligibles who are still working. Also included are disabled individuals under 65 who are insured government workers or widowed, and individuals of any age with end-stage renal disease, who are insured or receiving benefits (SSA or RR), or who are a dependent of such.
Some individuals age 65 and over, are eligible to receive Part A Medicare by enrolling and paying a premium for the coverage. This category includes individuals who are uninsured and are not receiving benefits (SSA or RR).
Individuals age 65 and over who are eligible for Part A coverage only if they pay a premium, may conditionally enroll in Part A pending a determination of eligibility for QMB. In this way, they are able to elect to receive Part A only if the premiums are paid by the state.
Interested individuals must go to the local Social Security office during the open enrollment period, or during the seven month eligibility period around their 65th birthday, and conditionally enroll for Part A Medicare. The Social Security office then refers the claimant to the local Family Support Division office for a QMB eligibility determination.
Claimants who are referred to the FSD office must request QMB application, or a QMB eligibility determination on an active assistance case. The claimant may provide a receipt from SSA as proof of application for Part A Medicare. The receipt contains the Part A Medicare application date. It does not state that the enrollment is conditional. This receipt is proof only of application for Part A Medicare; it is not proof of entitlement.
After the QMB application/request is made, the caseworker must send a IIVE for verification of eligibility for Part A Medicare. This must be done for each claimant. The SSA application process for Part A takes 2-4 weeks to complete; therefore, a IIVE does not show Part A Medicare participation immediately. Wait at least two weeks from the date of the application for Part A to send the IIVE.
Proof of conditional enrollment is shown on IIVE by a code of "Z99" in the field following the Hospital Insurance information, and includes an entitlement date. The "Z99" indicates that this is a conditional enrollment, and is considered as verification of Part A participation. It will be changed by SSA to a Missouri payer code when buy-in for Part A is complete.
In no instance should the client be approved for QMB coverage without verification of Part A eligibility.
For conditional enrollment cases, if the IIVE is returned showing no Part A entitlement, the caseworker must contact the local SSA office for clarification before the QMB application is rejected for no participation in Part A Medicare.
Make a determination of QMB eligibility on all factors including Part A participation. If the client is eligible on all factors, complete an IMU5 transaction establishing the QMB coverage. The effective date of QMB coverage must be the month following the month the determination is made, or the effective date of Part A entitlement, whichever is later.
Applications are occasionally received for the buy-in programs, Qualified Medicare Beneficiaries (QMB) and Specified Low-Income Medicare Beneficiaries (SLMB) from applicants in Alternative Care through the Children’s Division. These applications should be processed as per normal procedures. However, due to the way FAMIS is designed, the application will reject because of the applicant being in Alternative Care.
Please determine if the person would be eligible for the program (income, resources, and technical criteria). A trial budget should be entered on SELWIBCA. If the person is eligible, send an email request to COLE.MHNPOLICY@dss.mo.gov with subject line “Buy-In for AC Participant.” Please include the applicant’s name, DCN, and which level of buy-in for which the person is eligible (QMB or SLMB1).
A return email will be sent when coverage has been entered. Send a manual approval letter (IM-32) to the applicant.