Many people who are elderly or have disabilities have trouble paying the portion of medical bills left unpaid by Medicare and cannot afford private medigap insurance or a Medicare Advantage plan, but do not qualify for Medicaid. If this is your situation, you might be able to get help paying Medicare premiums and portions of Medicare-covered costs that Medicare does not pay. Three cost-reduction programs—called Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI)—are administered by each state’s Medicaid program. (In addition, you may also qualify for "Extra Help" paying for the Medicare Part D Prescription Drug Program.)
Qualified Medicare Beneficiary (QMB)
If you are eligible for Medicare and meet the income and asset eligibility requirements for the QMB program, your state's QMB program will pay all of your Medicare Part A and Part B premiums, deductibles, and coinsurance. Depending on how much you use Medicare-covered services in a year, this could mean a savings of up to several thousand dollars.
To be eligible as a QMB, your income must be no more than slightly above the Federal Poverty Guidelines (FPG), or Federal Poverty Level (FPL). This figure is established each year by the federal government; in 2013, the income level was $11,490 per year for an individual and $15,510 per year for a married couple. These figures are slightly higher in Alaska and Hawaii. It’s important to know, however, that certain amounts of income are not counted in determining QMB eligibility. Particularly if you are still working and most of your income comes from your earnings, you may be able to qualify as a QMB even if your total income is almost twice the FPG. QMB follows the SSI guidelines for countable income, which means roughly half of your income from work is not counted. If, after applying these rules, the figure you arrive at is anywhere close to the QMB qualifying limit ($978 in monthly countable income in 2013), it is worth applying for it.
There is a limit on the value of the assets you can own and still qualify as a QMB—generally, no more than about $7,000 for an individual and about $10,000 for a married couple. However, many assets, such as your house, your car, and certain personal and household goods, are not part of the resources that are counted. QMB follows the SSI guidelines for which assets are countable.
Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI)
If your income is slightly too high for you to qualify for QMB benefits, you may still be eligible for one of two other state medical assistance programs: Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individual (QI). The resource limits for eligibility are the same as for a QMB, but the income limits are 20%–80% higher, depending on the program.
If your counted monthly income—after the adjustments made in calculating income for SSI purposes—is under $1,313 for an individual, or $1,765 for a couple, you are likely to qualify for SLMB or QI support. (These figures go up slightly each year.)
Because the SLMB and QI programs are for people with higher incomes, they have fewer benefits than the QMB program. The SLMB and QI programs pay all or part of the Medicare Part B monthly premium, but do not pay any Medicare deductibles or coinsurance amounts. Nonetheless, this means potential savings of more than a thousand dollars per year.
Applying for QMB, SLMB, or QI
Before you can get coverage by the QMB, SLMB, or QI programs, you must file a written application separate from your Medicare application. If you are found ineligible for one program, you may still be found eligible for one of the others.
Where to File
To qualify for the QMB, SLMB, or QI programs, you must file a written application with the agency that handles Medicaid in your state—usually your county’s Department of Social Services or Social Welfare Department.
Required Documents and Other Information
Because eligibility for the QMB, SLMB, or QI programs depends on your financial situation, many of the documents you must bring to the Medicaid office are those that will verify your income and assets.
Although a Medicaid eligibility worker might require additional specific information from you, you will at least be able to get the application process started if you bring:
- pay stubs, income tax returns, Social Security benefits information, and other evidence of your current income
- papers showing all your savings and other financial assets, such as bankbooks, insurance policies, and stock certificates
- automobile registration papers if you own a car
- your Social Security card or number
- information about your spouse’s income and separate assets, if the two of you live together, and
- medical bills from the previous three months, as well as medical records or reports to confirm any medical condition that will require treatment in the near future. If you don’t have copies of these bills, records, or reports, bring the names and addresses of the doctors, hospitals, or other medical providers who are treating you.
Extra Help With Medicare Part D Costs
Anyone who qualifies for one of the above Medicare Savings Programs will also qualify for the Part D Extra Help program, which pays Part D premiums and deductibles for the prescription drug program.
What to Do If You Are Denied Coverage
If you are denied eligibility for QMB, SLMB, or QI, you have a right to appeal. If you believe you should be eligible for one of he programs, go to the office where you applied. Ask about the procedure in your state for getting a hearing to appeal that decision.
At an appeal hearing, you will be able to present any documents or other papers—proof of income, assets, medical bills—that you think support your claim. You will also be allowed to explain why the Medicaid decision was wrong.
The hearing itself is usually held at or near the welfare or social service office. You are permitted to have a friend, relative, social worker, lawyer, or other representative appear with you to help at the hearing. Although the exact procedure for obtaining this hearing, and the hearing itself, may be slightly different from state to state, they all resemble very closely the hearings given to applicants for Social Security benefits. For more information, see Nolo’s articles on Medicaid appeals.
Getting Assistance With Your Appeal
If you are denied QMB, SLMB, or QI, you may want to consult with someone experienced in the subject to help you prepare your appeal. One place you can find quality free assistance with these matters is the nearest office of the State Health Insurance Assistance Program (SHIP).
If there is no SHIP office near you, you may be able to find other assistance through your local senior center or by calling the Senior Information line listed in the white pages of your telephone directory. You can also hire a Medicaid lawyer or disability lawyer to help.