Texas Health and Human Services Commission
Medicaid for the Elderly and People with Disabilities Handbook
Revision: 14-2
Effective: June 1, 2014

Q-2000

Qualified Medicare Beneficiaries (QMB) – MC-QMB

Authorized under 42 U.S.C. §1396a(a)(10)(E)(i), the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles and coinsurance for a person who meets the requirements of this section. A person receiving Medicaid may also receive QMB benefits if the person meets the requirements of this section.

To be eligible for QMB coverage, a person must:

A person is not eligible for QMB coverage if the person:

Income

The income amounts are based on 100 percent of the federal poverty level (FPL) determined from the consumer price index and will be indexed each year. See Section Q-2500, QMB Income and Resource Limits.

Resources

Certain provisions of the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) were implemented Jan. 1, 2010. MIPPA changed the resource limits for the following Medicare Saving Programs (MSP):

The resource amounts are based on the consumer price index and will be indexed each year. The new resource limits for QMB, SLMB and QI-1, effective Jan. 1, 2014, are:

The resource limits prior to Jan. 1, 2010, were twice the SSI resource limits:

The resource limits prior to Jan. 1, 2010, which are twice the SSI resource limits, continue for the Qualified Disabled Working Individuals Program. See Section Q-6000, Qualified Disabled and Working Individuals (QDWI) – MC-QDWI.

A person's QMB eligibility begins on the first day of the month after the month the person is certified for QMB benefits.

A person with QMB coverage is not eligible for QMB in the three months prior to application or the months prior to onset of QMB eligibility.

Note: Persons age 65 or older residing in an IMD may be certified for QMB, if all eligibility criteria are met. Persons of any age residing in a state supported living center may be certified for QMB, if all eligibility criteria are met.

QMB ongoing is available for ICD/IID and state supported living center residents.

Use SSI policy to determine eligibility for this program.

The person must provide proof of the entitlement to enroll. The person may have a Medicare card or an enrollment letter from the Social Security Administration (SSA) documenting entitlement to Part A.

If the person has no proof of entitlement, refer the person to SSA for enrollment if the person:

The person must enroll himself; HHSC is not allowed to enroll the person for Part A as it does for Part B. The open enrollment period for Medicare is January through March, with benefits/premiums beginning in July.

Q-2100  Verification and Documentation for QMB

Revision 09-4; Effective December 1, 2009

Acceptable verification for Medicare enrollment for Part A includes:

  • Wire Third Party Query (WTPY);
  • State On line Query (SOLQ);
  • Medicare card;
  • an enrollment letter from the Social Security Administration documenting enrollment in Part A; and
  • presumptive eligibility (persons age 65 years and older receiving RSDI or Railroad Retirement can be presumed enrolled in Medicare Part A, unless their Social Security claim number suffix ends in J3, J4, K3, K4, K7, K8, KB, KC, KF, KG, KL and KM).

Q-2200  Conditional QMB

Revision 09-4; Effective December 1, 2009

Texas is a "buy-in" state. There is no restricted enrollment period. HHSC can automatically "add on" a person's Medicare Part A entitlement and pay the Medicare Part A premium at any time during the year. In other words, if the applicant has Part A, is enrolling for Part A or is entitled to Part A, the applicant may be certified for QMB.

Q-2210  Upon Certification of QMB

Revision 09-4; Effective December 1, 2009
  • If the person has Part B only (or is enrolling for Part B), the state will add on the person's Part A entitlement.
  • If the person has Part A only, the state will automatically add on the Part B entitlement.
  • The state will not pay any expenses until Part A and B premiums begin.

The only "conditional" left is if a person does not have Part A or B. However, we do not have to wait to put the person on QMB.

Q-2300  Social Security Administration QMB Referral Procedures

Revision 10-4; Effective December 1, 2010

Although most people who are eligible for Medicare Part A receive free Part A coverage, some are required to pay a monthly premium.

A person is entitled to Medicare Part A if the person meets one of the following conditions:

  • The person does not have to pay Medicare Part A, and is receiving Medicare Part A services as of the QMB determination.

    Example: Mrs. Smith applies for QMB benefits Aug. 15. She has a Medicare card with a Part A begin date of June 1. Since Medicare will pay for Part A services as of June 1, she is entitled to Part A at the time of the QMB determination.
  • The person is a Medicaid recipient or QMB or Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Disabled and Working Persons (QDWI) applicant and has never been enrolled in the federal Medicare system. In this case the person must apply at the local Social Security Administration (SSA) office for Part A Medicare eligibility. The person will receive a receipt that entitles the person to enrollment in Part A on the condition that the person 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 before the Part A begin date.

    Example: Mrs. Brown was never enrolled in the federal Medicare system. She applies for QMB. The eligibility specialist takes her application and pends it. Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare. She contacts SSA and is conditionally determined eligible for Part A. Her QMB application is completed.

The eligibility specialist may receive a referral from SSA. An application will be sent to a person with conditional Part A enrollment if there is not a current pending QMB application already on file.

The person's Wire Third Party Query (WTPY) verifies conditional Part A enrollment when the Social Security claim number ends in M and:
  • the Part A payment code status is Z99 and there is an entitlement date to Medicare Part B; or
  • there is no entitlement date for Part A and there is an entitlement date to Part B.

Proof of conditional enrollment in Part A fulfills the QMB eligibility requirement of entitlement to Medicare Part A.

Note: Do not presume that a person enrolled in Medicare Part B is also enrolled in Medicare Part A. Persons drawing early retirement (RSDI) (usually at the age of 62) are not eligible for Medicare Part A or B. Persons determined disabled by SSA and under age 65 are not eligible to enroll in Medicare until they have been disabled for 24 consecutive months or reach their 65th birthday, whichever comes first.

Q-2400  QMB Benefits

Revision 12-2; Effective June 1, 2012

QMB recipients do not receive regular Medicaid benefits. HHSC sends these persons a Your Texas Benefits Medicaid Card that reflects QMB status.

Medicaid pays out-of-pocket Medicare cost-sharing expenses for QMB recipients. Medicaid does not limit deductible or coinsurance payments to services covered by the State Plan.

Q-2500  QMB Income and Resource Limits

Revision 14-2; Effective June 1, 2014

Income Limits

The monthly income limits for initial certification are:

Date Range
Person
Couple
Deeming
Mar 1, 2014 to present
$973
$1,311
$338
Mar 1, 2013 to Feb 28, 2014
$958
$1,293
$335
Mar 1, 2012 to Feb 28, 2013
$931
$1,261
$330
Mar 1, 2011 to Feb 29, 2012
$908
$1,226
$318
Mar 1, 2009 to Feb 28, 2011
$903
$1,215
$312
Mar 1, 2008 to Feb 28, 2009
$867
$1,167
$300
Apr 1, 2007 to Feb 29, 2008
$851
$1,141
$290
Apr 1, 2006 to Mar 31, 2007
$817
$1,100
$283
Apr 1, 2005 to Mar 31, 2006
$798
$1,070
$272
Apr 1, 2004 to Mar 31, 2005
$776
$1,041
$265
Apr 1, 2003 to Mar 31, 2004
$749
$1,010
$261
Apr 1, 2002 to Mar 31, 2003
$739
$995
$256
Apr 1, 2001 to Mar 31, 2002
$716
$968
$252
Apr 1, 2000 to Mar 31, 2001
$696
$938
$242
May 1, 1999 to Mar 31, 2000
$687
$922
$235
Apr 1, 1998 to Apr 30, 1999
$671
$904
$233
Apr 1, 1997 to Mar 31, 1998
$658
$885
$227
Apr 1, 1996 to Mar 31, 1997
$645
$864
$219
Apr 1, 1995 to Mar 31, 1996
$623
$836
$213
Apr 1, 1994 to Mar 31, 1995
$614
$820
$206
Apr 1, 1993 to Mar 31, 1994
$581
$786
$205
Apr 1, 1992 to Mar 31, 1993
$568
$766
$198
Apr 1, 1991 to Mar 31, 1992
$552
$740
$188
Jan 1, 1991 to Mar 31, 1991
$524
$702
$178
Jan 1, 1990 to Dec 31, 1990
$471
$632
$161
Jun 1, 1989 to Dec 31, 1989
$424
$569
$145
Jan 1, 1989 to May 31, 1989
$409
$548
$139

Note: These amounts do not include the $20 disregard. Income cannot exceed the income limit for QMB eligibility.

Resource Limits

The monthly resource limits for initial certification are:

Date Range
Person
Couple
Jan 1, 2014 to present
$7,160
$10,750
Jan 1, 2013 to Dec 31, 2013
$7,080
$10,620
Jan 1, 2012 to Dec 31, 2012
$6,940
$10,410
Jan 1, 2011 to Dec 31, 2011
$6,680
$10,020
Jan 1, 2010 to Dec 31, 2010
$6,600
$9,910
Jan 1, 1989 to Dec 31, 2009
$4,000
$6,000

See Appendix XXXI, Budget Reference Chart.

Q-2600  QMB Cost-of-Living Adjustment

Revision 12-2; Effective June 1, 2012

For QMB eligibility, the cost-of-living adjustment (COLA) in Social Security benefits is currently excluded for the months of January and February. To determine eligibility for applications and redeterminations, use the pre-COLA benefit amount during those months.

This income exclusion applies only to eligibility for QMB, SLMB and QI. For QMB, SLMB and QI eligibility, the RSDI Title II COLA is excluded during a "transition month" until the publication of the federal poverty level (FPL). Based on federal law codified in 42 USC 1396d(p)(2)(D)(ii), "transition month" means each month in a year through the month following the month in which the annual revision of the FPL is published. If the federal publication of the FPL is available in March, the transition months would include January, February and March. If the federal publication of the FPL is available in February, the transition months would include January and February.

For years after 1998 through 2007, the exclusion of the Social Security COLA for January through March applies. Beginning in 2008, the exclusion of the Social Security COLA for January through February applies.

Reference: See Chapter E, General Income, for deeming of income.

Q-2700  QMB Medical Effective Date

Revision 12-4; Effective December 1, 2012

QMB eligibility begins on the first day of the month following the month the person is determined eligible for QMB benefits. The disposition date in the system of record is the date the eligibility decision is completed. For example, if the MC – QMB is signed and disposed on Jan. 2, QMB eligibility would begin on Feb.1.

There is no QMB coverage in the three months prior to the QMB application date or coverage for months up to the QMB effective date. The only exception is if the individual is eligible for continuous QMB. See details listed in Section Q-2800, Ensuring Continuous QMB.

Q-2710 Prior Coverage Under SLMB/QI-1

Revision 12-2; Effective June 1, 2012

Institutional living arrangement (including persons residing in state supported living centers and ICF/ID facilities, and persons age 65 and over residing in institutions for mental diseases (IMDs)).

Situation 1

A person does not reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Situation 2

A person does reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income, such as additional income was received in the prior months.

Note: Deeming and support and maintenance is not applicable to institutional or §1915(c) waiver programs but is applicable to QMB, SLMB, and QI-1.

Living in the community, including persons applying for Community Attendant Services (CAS) and persons residing at home and applying for §1915(c) waiver programs:

Situation

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual's income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Reminder

QI-1 persons cannot be eligible for regular Medicaid and QI-1 benefits at the same time. Always give applicants the opportunity to choose which benefit they prefer to receive and document the person's verbal or written choice of preferred benefit, including a choice between QI-1 and CAS benefits. For QI-1, the three months prior period cannot extend back into the previous calendar year unless the application was filed in that calendar year. The application file date and prior coverage months must be in the same calendar year.

Example 1: February is the application month, which makes January the only possible prior coverage month.

Example 2: December is the application month; thus, the three months prior would be September, October and November. Applicant could be potentially eligible for the three months prior, the application month of December and for January and ongoing.

Note: Refer to Section Q-3400, SLMB Medical Effective Date, for policy regarding the prior months.

Q-2800  Ensuring Continuous QMB

Revision 13-4; Effective December 1, 2013

If a denied SSI recipient applies for Medicaid under an MEPD program, verify whether the individual was also receiving QMB benefits at the time of the SSI denial by viewing the individual’s Medicaid History or Eligibility History in TIERS Inquiry. Verification also can be obtained by SOLQ/WTPY.

If a person is eligible for QMB and is applying for MC-QMB, enter the Continuous QMB Begin Month in the Program – Individual page in the system of record. This ensures continuous QMB coverage.

Examples:

  • The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is being certified under ME-Pickle and MC-QMB.
  • The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is certified under MC-QMB.

Technically, there is no limit as to how far back continuous QMB coverage may be given. However, system limitations will not allow Medicare Part B buy-in reimbursement to begin any earlier than two full fiscal years (with September considered the start of a fiscal year). The earliest buy-in date is based on the date that the buy-in process is successfully completed (not the eligibility specialist's decision date, the person's medical effective date [MED], or QMB effective date).

Examples:

  • SSI/QMB coverage denied Dec. 31, 2007
    Form H1200, Application for Assistance – Your Texas Benefits, filed April 7, 2010
    Eligibility determined on May 15, 2010, for continuous QMB; QMB MED = Jan. 1, 2008; buy-in process completed on July 15, 2010; buy-in effective January 2008 (current full fiscal year does not end until August 2010; earliest full fiscal year began September 2007)
  • SSI/QMB coverage denied Dec. 31, 2007
    Form H1200 filed Aug. 15, 2010
    Eligibility determined on Sept. 11, 2010, for continuous QMB; QMB MED = Jan. 1, 1998; buy-in process completed on Nov. 15, 2010; buy-in effective September 2008 (current full fiscal year began September 2010; earliest full fiscal year began September 2008)

If the QMB medical effective date precedes the earliest available buy-in date, the person can receive Medicaid coverage for Medicare co-payments and deductibles for the entire period established by the medical effective date. Buy-in coverage would begin later. A person may elect not to have continuous coverage if the medical effective date will not provide buy-in for the entire period and the person does not have any claims to cover or be reimbursed.

What is not considered continuous QMB:

  • QMB recipient was denied in error because income was incorrectly counted in the budget. The case needs to be corrected to add the missing coverage the recipient is entitled to receive.
  • QMB recipient was correctly denied for exceeding the income or resource limits. This is a valid denial and a break in coverage. These individuals cannot have continuous coverage if they reapply and are again eligible for QMB. The QMB effective date would be the first of the month after disposition.
  • QMB recipient was denied because the redetermination packet was lost or misrouted in the task list manager queue. The case needs to be corrected to add the missing coverage the recipient is entitled to receive.
  • QMB recipient was denied at redetermination for no packet received. At reapplication, this is not a continuous QMB, as the denial was valid. The QMB effective date would be the first of the month after disposition.

Q-2900  QMB Eligibility and Supplemental Security Income

Revision 13-4; Effective December 1, 2013

Persons receiving Medicaid benefits under SSI also may qualify for QMB. QMB status is automatically added to the Medicaid coverage when the person also receives Medicare Part A. QMB eligibility is effective the month after the tape match from SSA is received.

Example: The tape match with SSA is received in September 20XX indicating the SSI recipient is Medicare Part A eligible August 20XX. QMB eligibility will begin in October 20XX.

In situations where the SSI recipient should have QMB coverage but does not, the eligibility specialist emails all inquiries or necessary updates to CCC_Data_Integrity_Program@hhsc.state.tx.us. The turnaround time is 24 to 36 hours, depending on the number of inquiries received. Send the following information with your request:

  • Individual's number
  • Individual's name
  • Case number and EDG number
  • Medical coverage requested, including certification period
  • Add or delete coverage requested
  • Any special instructions that have to do with Medicaid coverage