How-to Qualify for Dual Eligibility (Medicare + Medicaid)
- You must be enrolled in Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care..
- You must prove your income is at or below the national poverty level.
- You must prove that you do not have cash value resources above a certain value.
- You must apply at your local MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. office.
Qualified Medicare Beneficiary (QMB) Program Details
For those who qualify, the federal QMB program pays the cost of their Medicare premiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. and co-insurance. These costs are typically paid by the Medicare beneficiaryA person who has health care insurance through the Medicare or Medicaid programs.. Beneficiaries qualify based on their monthly income and cash value assets.
If you’re enrolled in Medicare Part A, for your hospital insurance, and your income and resources meet the federal poverty threshold, you are most likely eligible to enroll in the QMB program. When you’re enrolled, your state’s Medicaid program pays some or all of your Medicare Part B premiumThe Medicare Part B premium is the monthly charge paid by beneficiaries for their outpatient medical care, services, and supplies. A beneficiary's premium may be uplifted by an IRMAA surcharge if their income is above..., Part A and Part B deductibles, and co-insurances. This is a significant financial relief for anyone qualified to receive the benefits. Some people call QMB the full benefit for dual-eligibleDual-eligible beneficiaries are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program.... beneficiaries.
QMB Eligibility Requirements
The rules are somewhat different for each state. The general federal guideline is that you must meet these basic requirements:
- You must be enrolled in Medicare Part A.
- Your normal monthly income must be at or below the national poverty level (updated annually).
- Excluding exempt property, you may not have cash resources that exceed a certain value. Your home, one car, and certain other personal items are not typically counted as resources.
Does the QMB Program Supplement Medicare?
QMB pays the beneficiary’s premiums, deductibles, and co-insurance through their state’s Medicaid program. In essence, it acts like a free MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. plan for the beneficiary, covering all Medicare-approved costs that most beneficiaries pay out-of-pocket. Some states require you to pay a small co-payment when you see a doctor.
Other Dual Eligible Programs
There are two other related programs:
- Specified Low-Income Medicare Beneficiary (SLMB); and
- Qualifying Individual (QI).
These programs help if your income is too high for QMB, but is within 20 percent above the federal income poverty level.
SLMB coverage helps people with their Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. monthly premium. If you qualify, you continue to pay your deductibles and co-insurance costs. Eligibility is the same as those for QMB, with the exceptionIn a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... of monthly income, which cannot exceed 120 percent of the national poverty level.
If your income is more than 120 percent of the federal poverty level, you may qualify under the QI program. If your income is less than 135 percent of the national poverty level, your state may pay your Medicare Part B premium if funds are available. This is a first first-come, first-served program, with a limited pool of funds. You must apply annually.
How-to Apply
If you’re enrolled in Medicare Part A and think you qualify for assistance, visit your local state Medicaid office.