Medicare Cost Sharing Coverage Groups

Medicare Cost Sharing Coverage Groups A. Qualified Medicare Beneficiaries (QMB) 1. Must have active Medicare Part A or Part B-ID or apply for Medicare as a condition of eligibility. Individuals with Medicare Part B only are also eligible as the Division of Medicaid will enroll the individual in Medicare Part A and pay any Part A premiums that are payable. 2. Countable income cannot exceed one hundred percent (100%) of the federal poverty level. There is no resource test but income produced by resources counts as income. 3. The effective date of Qualified Medicare Beneficiary (QMB) eligibility is the month after the month in which a determination is made that the individual is QMB eligible. 4. QMB-only benefits received are payment of monthly Medicare Part A and Part B or B-ID premiums and Medicare Parts A and B deductibles and co-insurance, beginning the month QMB-only coverage begins. 5. QMB-dual coverage means an individual is eligible as both a QMB and eligible in another full service category of eligibility. QMB-duals receive full Medicaid benefits and full Medicare cost sharing benefits. B. Specified Low Income Medicare Beneficiaries (SLMB) 1. Must have active Medicare Part A or active part B-ID or apply for Medicare Part A as a condition of eligibility. An individual with Medicare Part A only can be considered for coverage as the Division of Medicaid will enroll the individual into Medicare Part B and pay the monthly Part B or B-ID premiums. 2. Countable income must be greater than one hundred percent (100%) of the federal poverty level but not exceed one hundred twenty percent (120%) of the federal poverty level. There is no resource test but income produced by resources counts as income. 3. The effective date of SLMB eligibility is the first (1st) month of eligibility for SLMB, which includes the third (3rd) month before the month of application provided the Medicare Part A effective date is equal to the effective date of SLMB eligibility and the individual is otherwise eligible. 4. SLMB-only benefits received are payment of monthly Medicare Part B or B-ID premiums only. 5. SLMB-dual coverage means an individual is eligible both as a SLMB and eligible in another full service category of eligibility. SLMB-duals receive full Medicaid benefits and Medicare cost sharing benefits with the exception of payment of Medicare Part A premiums that may be payable by the individual. C. Qualifying Individuals (QI) 1. Must meet the same eligibility criteria as a SLMB and receives the same Medicaid benefit as a SLMB with the following exceptions: a) Countable income must be greater than one hundred twenty percent (120%) of the federal poverty level but not exceed one hundred thirty-five percent (135%) of the federal poverty level. b) There is no dual eligibility of a QI. 2. Payment of the Part B or B-ID premium for a QI is based on the availability of federal funding of the program, which is a capped allotment provided to each state. D. Qualified Working Disabled Individuals (QWDI) 1. QWDI’s are employed individuals who lose Medicare entitlement because their work exceeds the Substantial Gainful Activity (SGA) level for Title II purposes after an extended period of eligibility for Medicare. 2. The working individual must be under age sixty-five (65) and previously entitled to disability insurance benefits under Title II but lost Disability Insurance Benefit (DIB) due to earnings exceeding the SGA limit. 3. The individual must continue to have a disabling condition and must not be otherwise eligible for Medicaid. 4. The individual must be entitled to enroll in Medicare Part A; have countable income that does not exceed two hundred percent (200%) of the federal poverty level; and have resources that do not exceed an amount that is twice the SSI resource limit for an individual or couple, as appropriate. 5. All other non-financial criteria, using SSI policy rules, apply to QWDI eligibility. 6. The benefit received as a QWDI is payment of the Medicare Part A premium. 7. There is no dual eligibility for a QWDI.