QMB cases must be reinvestigated on a yearly basis. When QMB eligibility is concurrent with another type of assistance, reinvestigate QMB eligibility at the same time as the other type of assistance. When an individual is eligible as a QMB only, reinvestigate annually or as major changes occur, whichever is earlier.
For SSI/SP cases in combination with QMB, complete an annual reinvestigation of QMB eligibility only, to fulfill the reinvestigation requirements of the QMB program. Report the reinvestigation finding in the reinvestigation field of the SSI/SP IM-5/IMU5.
NOTE: When initially adding QMB to an SSI/SP case, enter a reinvestigation date in Field 47 to avoid an immediate delinquency.
For QMB eligibles, Part B Medicare premiums are paid through regular Buy-In procedures. Since this buying-in process takes 60-90 days to complete, it is essential that there are no breaks in a claimant's QMB eligibility. If a break does occur, the buying-in process must be started over, and the Part B premiums may not be paid for another 60-90 days. Thus, use the procedures in the following sections to ensure that breaks in QMB coverage do not occur in these situations:
When an individual who is receiving QMB coverage only, applies and is also eligible for another type of assistance, DO NOT CLOSE THE QMB CASE. Approve the new type of assistance and enter a “Y” in field 13M1, and RE-ENTER the old QMB eligibility date in field 13M2 of the new case. This action allows continuing coverage for QMB. On the same date that the approval action is processed, the system automatically closes the QMB-only case. The closing action appears on the Daily Transaction listing and generates a QMB turnaround IM-5 with a case action code of “29C” and a reason for closing of “39”.
When a QMB recipient is found to be ineligible for QMB at the time of approval for another type of assistance, enter an “N” in field 13M1 of the IMU5 of the new case. Make no entry in field 13M2 for this situation. The system automatically closes the QMB case when it opens the other type of assistance. A QMB turnaround IM-5 is generated with a closing code of “29C” and a reason for closing of “39”. NOTE: When taking this type of action, regular IM-80 procedures apply.
When a QMB recipient who is also receiving another type of assistance, becomes ineligible for the other type of assistance, but the QMB eligibility continues, action must be taken to close the other case using regular IM-5/IMU5 procedures. In addition, the system requires re-entry of the QMB indicator. Failure to make this re-entry will result in an on-line edit stating, “QMB INDICATOR AND BEGIN DATE ENTRY REQUIRED”. Re-entry requires a “Y” in field 13M1 and the original date of eligibility in field 13M2 of the IMU5. When the system processes the above transaction, it closes the other assistance case, and opens a “QMB-only” case. This transaction appears on the Daily Transaction listing and generates a QMB turnaround IM-5 with a case action code of “08C”.
NOTE: AN ENTRY OF “Y” IN FIELD 13M1 IS, IN EFFECT, AN APPROVAL CODE FOR QMB ASSISTANCE. DO NOT MAKE THIS ENTRY UNLESS CONTINUING ELIGIBILITY FOR QMB HAS BEEN ESTABLISHED.
Always use the IMU5 transaction when closing a case in this situation to allow the system to automatically open the QMB case in an overnight function. ICLS cannot be used when closing any type of assistance in combination with QMB. If you attempt to close this type of case with the ICLS function, you will receive the edit message, “QMB INDIVIDUAL ON CASE. USE IMU5 TO CLOSE.”
As in other assistance, the date of the closing of a QMB case affects what type of notification is required to be sent to the client.
If the closing action above occurs before the QMB payroll closing date, the client's name appears on the QMB payroll for the following month and a QMB card is issued. (Payroll closing for QMB-only occurs on the first payroll closing date).
If the closing action above occurs after the QMB payroll closing date, the Medicaid card from the other type of assistance is pulled (or the individual's name lined out). The client's name does not appear on the QMB payroll for the following month, therefore, the worker needs to send the client an IM-29(QMB) to show coverage for QMB for this one month. Send the IM-29(QMB) with the IM-33 notice advising the client of the closing of the other type of assistance.
Send an IM-33 to the claimant, notifying him/her of ineligibility for the other type of assistance. This notice should also contain an explanation of the claimant's continuing coverage for QMB, and include a copy of the IM-4QMB.
When a QMB recipient is found to be ineligible for both QMB and the other type of assistance (or is removed from both cases), close the case of the other type of assistance through the use of regular IM-5/IMU5 procedures. At the same time, close the QMB case by entering an “N” in field 13M1 of the IM-5/IMU5. (This is a required entry field for a closing. Failure to enter an alpha code in this field will result in an on-line edit).
NOTE: AN ENTRY OF “N” IN FIELD 13M1 IS, IN EFFECT, A CLOSING CODE FOR QMB ASSISTANCE. DO NOT MAKE THIS ENTRY UNLESS INELIGIBILITY FOR QMB HAS BEEN ESTABLISHED.
Send the client an IM-33 Notice of Ineligibility and include both the QMB case and the other type of assistance. Be sure to state the reasons for ineligibility in each program.