Medicare Savings Programs

Contents

  1. Introduction
  2. QMB (Qualified Medicare Beneficiary Program)
  3. SLMB (Specified Low-Income Medicare Beneficiary Program)
  4. QI (Qualified Individual Program – also know as ALMB)
  5. Obtaining QMB, SLMB, and QI Benefits
  6. Articles & Updates

Introduction

Assistance with Meeting the Costs of Medicare Premiums and Deductibles

The Qualified Medicare Beneficiary program (QMB), Specified Low-Income Medicare Beneficiary program (SLMB), and Qualified Individual program (QI), help Medicare beneficiaries of modest means pay all or some of Medicare’s cost sharing amounts (ie. premiums, deductibles and copayments). To qualify an individual must be eligible for Medicare and must meet certain income guidelines which change annually. The income guidelines, which are based on the Federal Poverty Level, change April 1 each year and can be found here.

Please note that the eligibility criteria listed below are federal standards; states may have more, but not less, generous standards (for example Connecticut currently has no asset limit for QI).

Note: Medigap premiums are not covered by QMB, SLMB, or QI.

QMB (Qualified Medicare Beneficiary Program)

The QMB Program Provides:

  • Payment of Medicare Part A monthly premiums (when applicable).
  • Payment of Medicare Part B monthly premiums and annual deductible.
  • Payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B.

Eligibility Criteria for QMB

  • The individual must be eligible for Medicare Part A (even if not currently enrolled).
  • The individual’s monthly income must be at or below 100% of the annual federal poverty level [FPL x 1]. The federal poverty level is announced early each year, and the income eligibility level for the Qualified Medicare Beneficiary program changes to reflect that figure each April.*
  • The individual must have resources below $7,280 for an individual and $10,930 for a couple in 2015. The resource limit for the QMB program is the same as for the Part D Low Income Subsidy program and is indexed each year according to the Consumer Price Index.)
  • Individual states may still eliminate or further increase the amounts above. For example, there is currently no asset limit for QMB in Connecticut and several other states.
  • An individual must undergo redetermination for the benefit every year. This involves submitting updated income and resource information to the state Medicaid agency.

Note: Individuals who are eligible for Medicare Part A but not enrolled, may conditionally enroll in Medicare Part A at any time during the year and then apply for QMB to cover the cost of the Medicare Part A premium which must otherwise be paid by voluntary enrollees (those not automatically eligible for Medicare Part A through Social Security or Railroad Retirement entitlement).This process, called the “Medicare Part A buy-in” is complex. For more information on the Part A buy-in see:

If an individual is enrolled in the QMB program, purchasing additional Medigap coverage for Medicare premiums, deductibles, and/or co-payments is unnecessary.

Access to Doctors and Other Providers for QMB Enrollees

The QMB benefit relieves a beneficiary of cost sharing associated with Medicare. This includes not only Part B premiums (and Part A premiums, when applicable) but also deductibles, copays and coinsurance. This includes any cost-sharing imposed by a Medicare Advantage plan. A provider is prohibited from billing a QMB beneficiary for Medicare Part A or B deductibles or co-insurance.  In essence, the QMB program operates like a basic Medicare Supplement policy (Medigap). QMB coverage can save a recipient hundreds or even thousands of dollars a year.

A state’s Medicaid program is supposed to pay the Medicare cost sharing on behalf of a QMB enrollee. This is true even for doctors who are enrolled in only Medicare and not Medicaid.  People with QMB are excused, by law, from paying Medicare cost-sharing. Providers are prohibited from charging them. All cost-sharing (premiums, deductibles, co-insurance and copayments) related to Parts A and B is excused, meaning that the individual has no liability.  The state has responsibility for these payments for QMBs.

However, provider billing for QMB operates in practice is complex, and many providers are unaware of how to 1) bill the Medicaid program on behalf of QMBs and 2) that even if they do not bill or are not reimbursed by the Medicaid program, they are strictly prohibited from seeking payment from QMB enrollees. It should, however, be noted that providers are under no obligation to treat QMBs or Medicaid enrollees.

A July 2015 Centers for Medicare & Medicaid Services (CMS) report, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), revealed several access to care problems for low-income Medicare beneficiaries enrolled in the QMB program.

The CMS study found that providers illegally balance-billed participants for Medicare cost-sharing on a regular basis. Due to a lack of information, confusion regarding the system, or concern over outstanding bills, most QMB enrollees participating in the study paid these bills. Additionally, participants reported that unpaid bills were submitted to collection agencies. Another finding in the study was that participants experienced challenges with the appeals process. The study also found that beneficiaries were dissatisfied with service coverage, particularly for Durable Medical Equipment (DME).

For more information on provider billing and QMB balance billing protections see:

SLMB (Specified Low-Income Medicare Beneficiary Program)

The SLMB Program Provides:

  • Payment of the Medicare Part B monthly premium only.

Eligibility Criteria for SLMB

  • The individual must be eligible for Medicare Part A (even if not currently enrolled).
  • The individual’s monthly income must be between 100% and 120% of the annual federal poverty level [between FPL and (FPL x 1.2)]. The federal poverty level is announced early each year. The income eligibility level for the Specified Medicare Beneficiary program changes to reflect that figure each April (Note: to this amount, add $20/month to represent the federally-allowed income disregard but check with your state to determine if your state allows a higher amount to be disregarded. Residents of Connecticut, for example, can add $227/month. Check each April for changes to this amount).
  • The individual must have resources below $7,280 for an individual and $10,930 for a couple in 2015. The resource limit for the SLMB program is the same as for the Part D Low Income Subsidy program and is indexed each year according to the Consumer Price Index . Individual states may still eliminate or further increase the amounts above. For example, there is no asset limit for SLMB in Connecticut and several other states.
  • An individual must undergo redetermination for the benefit every year. This involves submitting updated income and resource information to the state Medicaid agency.

QI (Qualified Individual Program – also know as ALMB)

The Balanced Budget Act of 1997 expanded the SLMB program for certain “qualified individuals” by increasing the income guidelines, but Congress only appropriated a limited amount of funds (a so-called “block grant”) to each state to pay for this expansion. Once a state’s appropriated money is gone, even eligible individuals will not be able to get into the program. After a series of short-term extensions, the benefit was permanently extended in April 2015 through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA – see Pub. L. No. 114-10, Apr. 16, 2015). The QI program is permanent now, rather than subject to periodic reauthorization tied to Medicare physician payment, as was the case for many years.

  • Individuals with incomes between 120% and 135% of the federal poverty level [between (FPL x 1.2) and (FPL x 1.35)] may be eligible for payment – through the SLMB program – of their Medicare Part B premium for the calendar year.
  • The individual must have resources below $7,160 for an individual and $10,750 for a couple in 2014. The resource limit for the QI program is the same as for the Part D Low Income Subsidy program and is indexed each year according to the Consumer Price Index.
  • Individual states may still eliminate or further increase the amounts above. For example, as of 2010 there is no asset limit for QI in Connecticut and several other states.
  • Individuals must re-apply every year for these benefits; state procedures for re-application will vary.
  • It is important to apply early in the year to have a better chance of obtaining these benefits. Applications from those meeting the eligibility requirements will be granted on a first come first served basis.
  • Priority for the following year will be given to those who received the benefits during the previous calendar year;
  • These benefits are not available to those who qualify for any other kind of Medicaid, for example Medicaid for the Aged, Blind and Disabled or Medicaid Spend-down.

Obtaining QMB, SLMB, and QI Benefits

Requests for applications for QMB, SLMB, or QI benefits are made to the state Medicaid agency. Eligibility for QMB is effective on the first day of the month following the month in which the Medicaid agency has all the information and verification necessary to determine eligibility. This should not take more than 45 days. SLMB and QI entitlement may be retroactive up to three months prior to the date of application if the person is otherwise eligible.

Remember income levels change April 1st each year.

For more information, please telephone your local Medicaid office. You can find your local Medicaid office at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html (site visited September 23, 2015).

Automatic Eligibility for the Low-Income Subsidy

Individuals enrolled in Medicaid or a Medicare Savings Program are automatically entitled to the full Part D Low-Income Subsidy, also called “Extra Help”. This means they should not have to apply for Extra Help through the Social Security Administration. The Low Income Subsidy can save Medicare beneficiaries thousands of dollars a year in Part D drug expenses Eligibility for extra help should go retroactive to the date of MSP entitlement.

For more information on the Low Income Subsidy/Extra Help visit http://www.medicareadvocacy.org/medicare-info/medicare-part-d/#LIS (site visited September 23, 2015).

Articles & Updates