Navigating the complexities of healthcare expenses can be a daunting task, especially for those approaching retirement age. With Medicare premiums, deductibles, and co-pays constantly on the rise, the financial burden can be overwhelming. In an uncertain economy, the struggle to cover medical bills adds an additional layer of stress. 

However, the Qualified Medicare Beneficiary (QMB) program may be a way to get some help. In this article, you’ll learn everything about the  QMB Medicare program, from what it covers to the eligibility criteria, and the application process. 

What is QMB Medicare?

The Qualified Medicare Beneficiary Program is a vital initiative that provides essential assistance to low-income Medicare beneficiaries. It typically serves individuals whose income exceeds the eligibility criteria for Medicaid, but who still require financial aid to manage their healthcare expenses. This program specifically covers Part A and Part B premiums, as well as cost sharing.

Additionally, individuals enrolled in Medicare QMB receive assistance through Medicare Prescription Drug Plan (Part D). This means that the out-of-pocket expenses for prescription medications are significantly reduced, allowing beneficiaries to pay only a nominal amount for each prescription.

According to the Centers for Medicare & Medicaid Services, in 2017, an estimated 7.7 million individuals, accounting for more than one out of eight people with Medicare, were enrolled in the QMB program.

What Does QMB Medicare cover?

The QMB Medicare program provides coverage for a range of essential healthcare expenses. Department of Health Care Finance breaks down what the program covers:

1. Medicare Part A and Part B premiums: The QMB program assists in paying for the premiums associated with both Part A and Part B of Medicare.
2. Medicare deductibles for Medicare-covered services: Qualified beneficiaries receive assistance in covering the deductibles for Medicare-covered services, reducing their out-of-pocket expenses.
3. Medicare co-insurance for Medicare-covered services: The QMB program helps alleviate the financial burden by covering the co-insurance costs for services covered under Medicare. 
4. Extra help paying for prescription drug costs under Medicare Part D: Beneficiaries enrolled in the QMB program receive additional support in managing their prescription drug expenses through the Medicare Part D benefit. This assistance ensures that the costs of medications are kept to a minimal amount.

Qualified Medicare Beneficiary income limits

To be eligible for QMB benefits, you must meet specific income requirements. These limits are updated yearly and are as follows for 2023:

• Individual monthly income limit: $1,235
• Married couple monthly income limit: $1,663

In addition to income limits, there are also resource limits to consider:

• Individual resource limit: $9,090
• Married couple resource limit: $13,630

Resource limits refer to the maximum value of assets an individual or married couple can have, such as savings accounts or investments, while still qualifying for QMB benefits. It’s important to meet both the income and resource limits to be eligible for the financial assistance provided by the QMB program.

What is QMB Plus?

QMB Plus or Full Dual beneficiaries are individuals who qualify for both Medicaid and Medicare benefits. As QMB Plus beneficiaries, they receive extra help with their healthcare costs. Medicaid covers their Medicare premiums, co-insurance, and deductibles for Medicare-covered services. They also get assistance with prescription drug costs through Medicare Part D. 

This means that individuals in QMB Plus only need to pay a small amount for their prescriptions. Overall, being a QMB Plus beneficiary ensures that individuals can access the healthcare services they need without facing overwhelming financial burdens.

Medicare QMB application

Applying for the Qualified Medicare Beneficiary (QMB) program is a straightforward process. Here’s how you can apply:

1. Visit the medicaid.gov website
2. Choose your state from the available options
3. Contact your state’s designated phone number or utilize their online application portal to begin the application process

By following these steps, you can initiate your application for the QMB program. It’s important to reach out to your state’s specific contact channels or utilize their online resources to ensure a smooth application experience.

Can a Medicare provider refuse a QMB patient?

As per Medicare’s official website, a healthcare provider can opt out of the Medicare program in which case they can refuse to treat a QMB patient at Medicare rates. However, if the provider has enrolled in the Medicare program, then they are not allowed to refuse service to patients enrolled in the Medicare QMB Program. 

Furthermore, Medicare pharmacies are also prohibited from billing individuals in the QMB program for any Medicare cost sharing. 

However, despite these protections, a study conducted by the Centers for Medicare & Medicaid Services in 2015 revealed that individuals in the QMB program were still being wrongly billed. 

How does QMB work with Medicare Advantage plans?

According to the Office of Healthcare Ombudsman and Bill of Rights, if you are enrolled in the QMB program, you don’t have to pay any costs for Medicare Advantage plans. This means that if you are enrolled in the QMB Medicare Savings program and it covers the costs, you do not need a separate Medicare Advantage Plan. Just make sure providers are aware of your QMB status to avoid any unnecessary charges.

Questions about Medicare?

Shoot us an email at medicare@hihella.com.