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32.2 QMB (Qualified Medicare Beneficiary)

32.2.1 QMB Introduction

32.2.2 Entitled to Medicare

32.2.3 QMB Income Limit

32.2.1 QMB Introduction

The following persons are Medicaid recipients who are automatically eligible for QMB benefits.

 

  1. Persons who are receiving or are eligible to receive SSI .

  2. 503 AGs.

  3. Disabled adult children.

  4. Widows and Widowers.

 

Widow/widowers (See 25.3 Widows and Widowers), DAC’s (See 25.2 DAC) and 503’s (See25.1 503 Eligibility) have the option of not taking the QMB benefit.  

 

If the person does not belong to one of the above named groups, s/he must:

  1. Be non-financially eligible for Medicaid or BadgerCare Plus.

  2. Be entitled to Medicare Part A.

32.2.2 Entitled to Medicare

A person is "entitled" to Medicare Part A if s/he meets one of the following conditions:

 

  1. S/he does not have to pay Medicare Part A, and s/he is receiving Medicare Part A services as of the QMB determination.

 

Example 1: Mrs. Smith applies for QMB benefits August 15, 1989.  She has a Medicare card with a Part A begin date of June 1, 1989.  Since Medicare will pay for Part A services as of June 1, 1989, she is "entitled" to Part A at the time of the QMB determination.

 

  1. S/he must pay a monthly premium to receive Medicare Part A, and s/he fits one of the following descriptions:

 

  1. S/he is a Medicaid recipient and has been enrolled in Medicare sometime in the past.  In this case the State will attempt to enroll him/her in Medicare Part A.  QMB eligibility cannot begin prior to the Part A begin date.

 

Example 2: Mr. Helmuth's Part A lapsed because he did not work enough quarters for free enrollment and he could no longer afford the premiums.  When he becomes eligible for Medicaid, the State will begin paying his Medicare premiums.

 

    1.  S/he is a Medicaid recipient or QMB or SLMB or QDWI applicant and has never been enrolled in the federal Medicare system.  In this case s/he must apply at the local SSA office for Part A Medicare eligibility.  S/he will receive a receipt which entitles him/her to enrollment in Part A on the condition that s/he is found eligible for QMB or SLMB.  The receipt from SSA will have a Part A begin date on it.  QMB OR SLMB or QDWI eligibility cannot begin prior to the Part A begin date.

 

Example 3: Mrs. Brown was never enrolled in the federal Medicare system.  She applies for QMB.  Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare.  She goes to the SSA office during the January-March enrollment period and is conditionally determined eligible for Part A effective July 1st.  She applies for QMB at the IM Agency on May 1st.  She becomes QMB eligible as of July 1st.

32.2.3 QMB Income Limit

The QMB income limit is 100% of the federal poverty level (FPL).  See 39.5 FPL Table.

 

The method of counting income is based on the SSI method, not on the spousal impoverishment method. (See 28.1 HCBWLTC Introduction). Calculate QMB net income as follows:

 

$ Earned income (See 15.5 Earned Income)

- $65 and ½ earned income deduction (15.7.5 $65 and ½ Earned Income Deduction)

+ Unearned income (social security income, etc.) (15.4 Unearned Income)

- Special exempt income (15.7.2 Special Exempt Income)

- $20 standard deduction

= Net income used to determine QMB eligibility

 

When counting social security income, use gross social security income.  Gross social security income:

  1. Of a self-payer = the social security check amount + Medicare premiums s/he has paid.

  2. Of someone for whom the State is paying the premiums = the social security check amount.

 

Disregard the COLA increase for the current year until the month after the new federal poverty limits become effective.

 

Example 4: Big Al is a QMB recipient.  He has income of $900.00.  The QMB income limit in December is $907.50.  In January, a COLA increase of $11.17 increases Big Al's income to $911.17.  Disregard the COLA increase in any determination of Big Al's continuing QMB eligibility.  On April 1st, new, higher QMB in-come limits are published.  Redetermine Big Al's QMB eligibility in May.  At this redetermination, do not disregard the January COLA increase.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This page last updated in Release Number: 12-01

Release Date: 03/21/12

Effective Date: 03/21/12