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QMB Basics

Dually eligible beneficiaries are low-income beneficiaries enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A, Part B, or both, and getting full Medicaid benefits or only help with Medicare premiums or cost-sharing.

Billing Dual Eligible/QMBs

Medicare providers cannot bill QMB beneficiaries for Medicare cost-sharing. This includes Medicare deductibles, coinsurance, and copayments. In some cases, a beneficiary may owe a small Medicaid copayment. Medicare and Medicaid payments are considered payment in full.

This prohibition applies even if the provider or supplier doesn’t participate in Medicaid, does not apply if the provider does not participate in Medicare.

Providers are subject to sanctions if they bill a QMB above the total Medicare and Medicaid payments, even when Medicaid pays nothing. If a provider bills a QMB for Medicare cost-sharing, or turn a bill over to collections, the provider must recall it. If a provider collects any QMB cost-sharing money, it must be refunded.

Verifying Dual Eligible/QMB

Providers should use the Medicare 270/271 HIPAA Eligibility Transaction System (HETS) and the Medicare Remittance Advice to identify if a beneficiary is a QMB and owes no Medicare cost-sharing.

Advanced Beneficiary Notification of Non-Coverage (ABNs)

Providers cannot bill the dually eligible beneficiary up front even when an ABN is provided. Once Medicare and Medicaid adjudicates the claim, the provider may only charge the beneficiary in these circumstances:

  • If the beneficiary has QMB coverage without full Medicaid coverage and Medicare denies the claim, the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy.
  • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy, subject to state laws that limit beneficiary responsibility.

Types of Dually Eligible Beneficiaries

 Full Medicaid 


 Benefits

Full Medicaid coverage refers to the package of services beyond Medicare premiums coverage and cost-sharing certain beneficiaries get when they qualify for certain eligibility groups under a state’s Medicaid Program. States must cover some of these groups (like Supplemental Security Income [SSI] recipients). States have the option to cover others, like the special income level institutionalized beneficiary group, home- and community-based waiver participants, and medically needy individuals.

Dually eligible beneficiaries who get Medicaid only are enrolled in Part A and or Part B and qualify for full Medicaid benefits but not for MSP groups. States may pay their Part B premium.
 Qualifications 

States decide income and resource criteria.

States can require Part A or B enrollment if they pay the beneficiary’s premiums for these parts.

Beneficiaries must show they need a certain level of care or meet state-specific medical criteria to qualify for certain categories.


 QMB Only Without Other Medicaid  
 Benefits

Medicaid pays Part A (if any) and Part B premiums.

Medicaid is liable for Medicare deductibles, coinsurance, and copayments for Medicare-covered items and services. Even if Medicaid doesn’t fully cover these charges, the QMB isn’t liable for them.
 Qualifications 

Income can be up to 100% of the Federal Poverty Level (FPL).

Resources can’t be more than 3 times the SSI resource limit, increased annually by the Consumer Price Index (CPI).

QMB qualifications include enrollment in Part A (or if uninsured for Part A, have filed for premium Part A on a conditional basis).


 Qualified Medicare Beneficiary Plus (QMB+)   
 Benefits

Medicaid pays Part A (if any) and Part B premiums.

Medicaid is liable for Medicare deductibles, coinsurance, and copayments for Medicare-covered items and services. Even if Medicaid doesn’t fully cover these charges, the QMB+ isn’t liable for them.

Get full Medicaid coverage plus Medicare premiums and cost-sharing coverage.
 Qualifications  Meet QMB-related eligibility requirements described in Table 2 and full Medicaid eligibility requirements in Table 1.


 Specified Low-Income Beneficiary (SLMB) Only Without Other Medicaid  
 Benefits Medicaid pays Part B premium.
 Qualifications 

Income between 100%–120% of FPL.

Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

Enrolled in Part A.


 Specified Low-Income Medicare Beneficiary Plus (SLMB+)  
 Benefits

Medicaid pays Part B premium.

Get full Medicaid coverage plus Medicare Part B premium coverage (see Table 1 for a definition of full Medicaid coverage).
 Qualifications  

Meet SLMB-related eligibility requirements described in Table 4 and full Medicaid eligibility requirements in Table 1.


 Qualifying Individual (QI)  
 Benefits

Medicaid pays Part B premium.

Benefits limited to first-come, first-served.
 Qualifications 

Income between 120%–135% of FPL.

Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

Enrolled in Part A.

QI beneficiaries aren’t eligible for any other Medicaid coverage.


 Qualified Disabled Working Individual (QDWI)  
 Benefits  Medicaid pays Part A premium.
 Qualifications 

Income up to 200% of FPL.

Resources up to 2 times the SSI resource limit.

Individuals under 65 with a qualifying disability who lost premium-free Part A coverage after returning to work and now must pay a premium to enroll in Part A.

QDWI beneficiaries aren’t eligible for any other Medicaid coverage.


Reference

MLN Booklet: Dually Eligible Beneficiaries Under Medicare and Medicaid

ICN MLN006977

February 2022

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