0865.035.00 QMB IN CONJUNCTION WITH spend down

QMB eligibility can be established regardless of eligibility for other types of assistance. However, for Medical Assistance recipients, clearly explain options to the client, as QMB eligibility may alter how the client receives Medicaid coverage.

0865.035.05 Non-spend down may become spend down when adding QMB

When an individual becomes eligible for QMB coverage, the SMI premium is no longer an allowable deduction on the Medical Assistance budget. This may cause a non-spend down MA recipient to become a spend down recipient. Further, any medical expenses paid through the QMB program cannot be used to meet the claimant's spend down. Therefore, the worker needs to explain this option to the claimant, and allow the claimant to make a choice as to which coverage s/he prefers.

These options are illustrated in the following example:

Ms. Crosby is a non-spend down MA recipient. She receives SSA of $450.80 which includes her SMI premium. Her net SSA check is $419.00. She is receiving Part A Medicare and is eligible for QMB on all other factors.

If she elects to receive QMB coverage, she will no longer have her SMI premium deducted from her MA budget, which will result in a spend down of $8.80. She will have to decide if she will incur at least $8.80 in applicable medical expenses each month, and could use the additional coverage the QMB card allows, or if it would be more beneficial to forgo the additional QMB coverage and not have to incur a set amount of medical expenses each month.

0865.035.10 Special procedures for QMB/spend down combination approvals

Some specialized procedures are necessary when processing QMB cases in conjunction with spend down. Examples of these procedures follow:

If an active QMB recipient becomes spend down, the QMB coverage does not terminate at the end of the month as the MA coverage does. The QMB coverage carries over from one month to the next and is not interrupted unless some other factor causes ineligibility. When a QMB-only recipient becomes eligible for MA spend down, do not close the QMB case. Approve the MA case and show QMB eligibility with a “Y” indicator in field 13M1 along with the original QMB eligibility date in field 13M2. (IMU5 shows the indicator and date to be re-entered.) On the date the transaction is processed, the system automatically closes the QMB-only case. QMB coverage is continued through the MA spend down case with the QMB indicator.

On new spend down approvals, the caseworker must send an approval letter (IM-32SPDN) notifying the claimant they have been approved for spend down, but full Medicaid coverage will not begin until the spend down is met. Further, the worker should include a note to the claimant on the IM-32 which states, “Your QMB coverage continues unless you are otherwise notified. It is not interrupted by your spend down coverage ending.” The letter will inform the claimant of the spend down amount and the months for which they can receive coverage by meeting spend down. If the worker has already received bills to meet spend down for some of the months, the letter includes the dates of coverage for those months.

0865.035.15 Budgeting procedure when MA and QMB applications are approved in the same month

If a claimant applies for MA and QMB and is approved for both in the same month, the SMI premium can only be considered as a budget deduction for a the months the they will not receive QMB. If this deduction would have allowed the claimant to be a non-spend down for MA, the claimant may be a spend down when QMB is approved, as this deduction cannot be considered. If a QMB approval results in the claimant no longer being eligible for Medical Assistance on a non-spend down basis, the case must be changed to spend down effective the first day of the month following the month the QMB approval is entered in the IMU5 system.

When the MA and QMB applications are approved at the same time, the SMI premium can only be used as a deduction for the months before QMB eligibility begins.

REMEMBER: QMB eligibility can never start in the month of application. It must begin the month AFTER the determination is made.

The following example illustrates how the Medicare premium deductions are used for this initial approval:

Ms. Trout applied for MA and QMB on April 1, 2004. She is ready to be approved for both programs on May 10, 2004. Her only income consists of $784.60 from SSA which includes the SMI premium of $66.60. Her Medicaid coverage through the Medical Assistance program begins on April 1, 2004, and her QMB coverage begins on June 1, 2004. Income figures are as follows:

In the above situation, April and May are the only months Ms. Trout will be paying her own SMI premium, based on her QMB approval. (Remember: QMB eligibility begins the month after the month of approval).

On May 10 enter the case in the IMU5 system as a non-spend down case without QMB. On May 11 change the case to spend down effective June 1, 2004 and enter a “Y” in field 13M1 and enter the QMB eligibility date in field 13M2.

0865.035.20 Medical expenses allowed in QMB/spend down budgeting

In determining spend down eligibility when the recipient is also eligible for QMB, use only those incurred allowable medical expenses which would not be covered by the QMB program. When spend down eligibility is determined in the same quarter in which a claimant becomes QMB eligible, allow incurred medical expenses as for any other spend down claimant until the month QMB eligibility is effective. In the month(s) QMB is effective, use only those allowable expenses which would not be covered by the QMB program.

NOTE: Medical expenses paid by Medicare in combination with QMB are not allowable as spend down expenses. (Refer to Section 0810.010.15 . )