QMB Categories Explained

Without other Medicaid (QMB Only – also known as QMB “partial benefit”) are enrolled in Medicare Part A (or if uninsured for Part A, have filed for premium Part A on a conditional basis), have income up to 100% of the federal poverty level (FPL) and resources that do not exceed three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation, and are not otherwise eligible for full-benefit Medicaid coverage. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost sharing amounts, including deductibles, coinsurance and, copays. Providers can bill Medicaid programs for these amounts, but states have the option to reduce or eliminate the state’s Medicare cost sharing payments by adopting policies that limit payment to the lesser of (a) the Medicare cost sharing amount, or (b) the difference between the Medicare payment and the Medicaid rate for the service.

meet the QMB-related eligibility requirements described above and the eligibility requirements for a separate “categorical” eligibility group covered under the state Medicaid plan. In addition to the coverage for Medicare premiums and cost-sharing described above, QMB “Plus” individuals are entitled to the full range of Medicaid benefits applicable to the separate eligibility group for which they qualify. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost sharing amounts, including deductibles, coinsurance, and copays. Providers can bill Medicaid programs for these amounts, but states have the option to reduce or eliminate the state’s Medicare cost sharing payments by adopting policies that limit payment to the lesser of (a) the Medicare cost sharing amount, or (b) the difference between the Medicare payment and the Medicaid rate for the service. QMBs with full-benefit Medicaid pay no more than the Medicaid coinsurance (if applicable) for services covered in the state plan (i.e., care that is furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover).

are enrolled in Part A and have income between 100 and 120 percent of the FPL, and resources that do not exceed three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation. Medicaid pays only the Medicare Part B premiums for this group.

meet the SLMB-related eligibility requirements described above, and the eligibility requirements for a separate “categorical” eligibility group covered under the individual’s state Medicaid plan. In addition to the coverage for Medicare Part B premiums, these individuals receive fullbenefit Medicaid coverage (i.e., the package of benefits provided to the separate eligibility group for which they qualify). SLMBs with full-benefit Medicaid pay no more than the Medicaid coinsurance (if applicable) for services covered in the state plan (i.e., care that is furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover). These individuals pay Medicare costsharing for Medicare-covered care not included in the state plan unless the state chooses to pay these costs.

are enrolled in Part A and have income of at least 120% but less than 135% of the FPL and resources that do not exceed three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation. QIs are never eligible for a separate eligibility group covered under the state Medicaid plan. QIs receive coverage for their Medicare Part B premiums, to the extent their state Medicaid programs have available funding. The federal government makes annual allotments to states to fund the Part B premiums.

became eligible for premium-free Part A by virtue of qualifying for Social Security disability insurance, but lost those benefits, and consequently Premium-free Medicare Part A, because they returned to work. QDWIs have income that does not exceed 200% of the FPL, resources that do not exceed two times the SSI resource standard, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.

These individuals are entitled to Medicare Part A and/or enrolled in Part B, and qualify for full Medicaid benefits, but not the QMB or SLMB programs. Full benefit Medicaid coverage refers to the package of services, beyond coverage for Medicare premiums and cost-sharing, that certain individuals are entitled to when they qualify under eligibility groups covered under a state’s Medicaid program. Some of these coverage groups are ones states generally must cover (for example, supplemental security income (SSI) recipients) and some are ones states have the option to cover (for example, the “special income level” group for institutionalized individuals, home- and community- based services (HCBS) programs participants, and “medically needy” individuals). Some of the services in the Medicaid benefit package are ones Medicare does not cover, such as certain long-term services and supports (LTSS), behavioral health, transportation, and vision services. Medicaid benefits vary by state. A full-benefit Medicaid beneficiary pays no more than the Medicaid coinsurance (if applicable) for services covered in the state plan (i.e., care that is furnished by a Medicaid provider and that either: (1) Medicaid and Medicare, or (2) Medicaid, but not Medicare, cover). These individuals pay Medicare cost-sharing for Medicare-covered care not included in the state plan unless the state chooses to pay these costs.