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Qualified Medicare Beneficiary (QMB) program

What is the Qualified Medicare Beneficiary (QMB) program?

Some Medicare beneficiaries struggle to pay for Medicare premiums and cost sharing even though their incomes are too high to qualify for full Medicaid benefits. A group of Medicaid-administered programs – Medicare Savings Programs (MSPs) – pay for Part B premiums for these enrollees. The most commonly enrolled in MSPs are the Qualified Medicare Beneficiary (QMB) program, Specified Low-Income Medicare Beneficiary (SLMB) program, and Qualified Individuals (QI) program.

QMB goes further than the other MSPs – and also covers an enrollee’s Medicare Part A and B cost sharing (e.g. deductibles, co-insurance, and co-pays) and Part A premiums (if an enrollee owes them). And although QMB does not reimburse for cost sharing owed under Part D, all QMB enrollees receive Extra Help – a federal program that lowers their Medicare Part D drug costs.

Medicaid used to pay for QMB enrollees’ Part A and B cost sharing based on Medicaid fee-for-service payment rates. But the Balanced Budget Act of 1997 allowed states to limit their cost sharing payments for QMB enrollees when Medicare’s payment was at least equal to what would have been reimbursed under Medicaid. (Medicaid typically pays less than Medicare does for the same services.)

When Medicare’s payment is higher than the Medicaid rate for a service, Medicaid may not pay anything for QMB cost sharing – but QMB enrollees still cannot be billed more than a small co-pay (if one is allowed under Medicaid). (Specifically, states are allowed to limit QMB cost sharing payments to the lesser of the Medicare cost sharing amount or the difference between the Medicaid rate and Medicare’s payment.)

And Medicaid will not reimburse for QMB cost sharing at all if a provider hasn’t enrolled in the Medicaid program. This can create a tricky situation for health care providers who aren’t accustomed to treating dual eligibles – and is a reason some enrollees choose not to share their status as a QMB with every medical provider.

Medigap insurers cannot knowingly sell a Medicare supplemental insurance policy to QMB enrollees (and this restriction also applies to those receiving full Medicaid benefits). Some individuals sign up for a Medigap policy – and use its premium costs as an ‘income disregard’ to become eligible for QMB benefits. These individuals can continue to be enrolled in Medigap, but usually can’t purchase a different Medigap plan.

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