0865.010.10 FINANCIAL NEED (QMB)

Medical Assistance budgeting methodologies apply to QMB except where noted.

0865.010.10.05 Assistance Group

Although QMB eligibility is determined on an individual basis, the income and resources of certain household members are considered when establishing need.

Those whose income and resources are to be considered are:

• the claimant;
• the claimant's spouse, if living together; and
• Part A eligible dependent children in the home.

NOTE: Dependent children are not considered in the assistance group with a Part A eligible parent unless they are also eligible for Part A Medicare.

Part A Medicare eligible dependent children (under age 18) of parents who are ineligible for QMB are subject to the deeming procedures of Medical Assistance for Disabled Children. Refer to Section 0805.020.00.

For married couples living together, include both in the assistance group, even if one is receiving another type of assistance.

0865.010.10.10 QMB Income Standard

The QMB income standard is 100% of the Federal Poverty Level for the size of assistance group involved. Effective April 1, 2018 QMB standards are as follows:

The QMB income standard is absolute and a person may NOT “spenddown” to become eligible.

0865.010.10.15 Income Considered

All income, earned and unearned, that is considered for the MO HealthNet for the Aged, Blind, and Disabled (MHABD) program is also considered for QMB.

0865.010.10.20 Income Exemptions/Deductions

All income exemptions used for Medical Assistance budgeting apply for the QMB program. Also exclude the following cash grants: Temporary Assistance, SP, BP, SAB, and SNC.

As a result of federal legislation, effective January 1, 1991, cost of living (COLA) increases in OASDI and SSI which are received in January of each year cannot be considered on the QMB budget until the effective date of the Federal Poverty guidelines in April of the same year.

Senate Bill 577 (2007) amended Section 208.153 RSMo to specify that programs in which income eligibility is determined by Federal Poverty Level (FPL) will not be adjusted for annual Cost of Living Adjustment (COLA) changes in OASDI or SSI benefits until the next FPL adjustment.

FAMIS disregards the COLA amount entered for January's income for the QMB program until the next FPL adjustment for April.  SSA and SSI incomes for individuals in any FAMIS EU entered after the adjustment must include the pre-COLA adjusted amount for December and the COLA-adjusted amount for January with a verification code of CO (COLA).

0865.010.10.25 Completion of the QMB budget

Compute the QMB budget using the IM-30A. QMB budgeting procedures follow those of Medical Assistance (refer to Section 0805.015.00 ) with the following exceptions:

• No deduction from income is allowed for medical insurance premiums on the QMB budget.  This includes the SMI premiums for Medicare.
• Income is notrounded down to the nearest whole dollar amount.

For each applicant, the worker must consider gross income of the assistance group, minus all allowable deductions. The resulting net income is compared to the QMB standard (based on assistance group size) to determine eligibility. If net income exceeds the standard, the claimant is not eligible. If net income is equal to or less than the standard, the claimant is eligible. Following are representative examples of QMB budgeting situations:

EXAMPLE #1:

Mr. Smith is age 67. His only income is Social Security of $780.90 per month. He is enrolled in Part A Medicare. His SMI premium of $104.90 per month is deducted from his Social Security check for a net check of $676.00. His wife, age 56, lives with him in the home. She has no income of her own and there are no other household members.

Mr. Smith is income eligible for the QMB program.

EXAMPLE #2

Mrs. Jones receives Social Security disability payments of $1203.90 per month. She is enrolled in Part A Medicare. Her Part B premium of $104.90 per month is deducted from her check for a net check of $1099.00. Mr. Jones and their two children, ages 12 and 14, reside in the home. Mr. Jones is employed earning $900.00 per month. He pays a medical insurance premium of $159.00 per month for himself and Mrs. Jones. The children each receive a Social Security benefit of $68.00 per month.

Mrs. Jones is not QMB eligible. The needs and income of ineligible children are not considered. Mrs. Jones cannot “spenddown” or use the medical insurance premium to become QMB eligible.

EXAMPLE #3

Mr. and Ms. Black are both over age 65. They are both enrolled in Part A Medicare. Mr. Black has Social Security of $1200.90. Ms. Black has Social Security of $900.90. The SMI premiums are deducted from their checks for net checks of $1096 and $796 respectively. There are no other household members.

Neither Mr. nor Mrs. Black is eligible for QMB coverage.