Depending on certain criteria, a person with original Medicare (Part A and Part B) or a Medicare Advantage (Part C) can apply for the QMB program.
Medicare helps people with limited income and savings pay for their healthcare costs through Medicare Savings programs (MSPs). The Qualified Medicare Beneficiary (QMB) program is one of four available MSPs.
In this article, we look at the QMB program, what it covers, and the income and resource limits. We also explain eligibility and enrollment limits. We then discuss Extra Help, and other MSPs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
In 2017, the Qualified Medicare Beneficiary (QMB) program helped more than 7 million people pay their Medicare costs, including premiums, deductibles, coinsurance, and copays.
The QMB program is one of four Medicare Savings Programs (MSPs). The other three programs are:
- Specified Low-Income Medicare Beneficiary (SLMB) program
- Qualifying Individual (QI) program
- Qualified Disabled and Working Individuals (QDWI) program
Medicare developed these programs to help Medicare beneficiaries with low income pay their healthcare costs.
If a person qualifies for an MSP, the program may also pay the coinsurance, deductibles, and copays for Medicare parts A and B.
The QMB program covers Medicare Part A and Part B premiums, and some out-of-pocket costs, such as deductibles, copays, and coinsurance.
When a person gets medical care, they should tell their healthcare provider they have QMB program coverage. They should also show the provider their Medicare and QMB program cards.
What if I get a bill?
Generally, if a person gets a bill they believe the QMB program should cover, they can get a refund. There are 3 ways a person can get help:
- Contact Medicare at 800-MEDICARE. Medicare will contact the healthcare provider and confirm the QMB program covers the individual and refund any payments already made.
- Show their Medicare Summary Notice (MSN) to the provider. The notice confirms a person is in the program. A person can get their MSN by logging in to their MyMedicare.gov account.
- Contact the Consumer Financial Protection Bureau (CFPB). If a person is being contacted by a debt collector, they can call the CFPB at no cost on 1-855 411-2372, or they can reach the CFPB online.
Someone can enroll in a QMB program providing they meet the monthly income limits.
For an individual, the limit is $1,084 per month. For a married couple, the combined income must be less than $1,457 per month. The income limits are slightly higher in Alaska and Hawaii.
The income limit increases annually to allow for general inflation and the cost of living.
Other financial resources count toward the QMB resource limit. These items include:
- money in checking accounts
- money in savings accounts
Some parts of an individual’s property do not count towards the resource limit, such as:
- a primary home where the individual lives
- a primary vehicle
- personal items
- a pre-paid burial plot
- a limited burial plan
In 2020, the resource limits are $7,860 for an individual and $11,800 for a married couple.
As with income limits, the resource limits also increase annually.
People with original Medicare parts A and B or a Medicare Advantage plan (Part C) can apply for the QMB program.
Individuals must fulfill the following eligibility criteria:
- have or be eligible for Medicare Part A
- live in the state where they are applying for the QMB program
- have limited income, savings, and resources
The individual state’s Medicaid program administers all Medicare MSPs, including the QMB program, and decides if an individual is eligible for the QMB program.
Typically, states use the Federal Poverty Level (FPL) for income and resources, but the calculations may differ between states.
If an individual wants to apply for the QMB program, they should contact their state Medicaid office. This online tool can help a person find the right contact information. A Medicaid representative can confirm their eligibility and explain the application process.
Typically, the person making the application must complete a form and provide supporting documentation.
If someone needs more assistance, they can contact their local State Health Insurance Assistance Program (SHIP).
Because people’s financial situation can change, they must reapply each year to continue receiving the QMB program benefits. An individual’s state Medicaid office can provide information about the reapplication process.
An individual who qualifies for the QMB program automatically qualifies for Medicare Extra Help.
Medicare established this program to help people to pay for their Medicare Part D prescription drug coverage. It offers financial assistance for premiums, deductibles, and other associated prescription drug costs.
In 2020, the copay is a maximum of $3.60 for generic drugs and $8.95 for brand name drugs.
Extra Help does not apply to any Medicare Advantage plans or Medigap plans.
How to apply for Extra Help
After the QMB program accepts an individual’s application, they are automatically qualified for the Extra Help program. Individuals can enroll online on the Social Security Administration (SSA) website.
In August each year, the SSA reviews an individual’s income. Depending on the decision, a person’s Extra Help benefits may remain the same, increase, decrease, or end.
If an individual does not meet the QMB program’s qualifying requirements, they can check if another MSP could help them. The table below compares the four MSPs. The income limit is shown as a percentage of the FPL.
|Qualified Medicare Beneficiary (QMB)||100% of FPL||Medicare Part A and Part B premiums, deductibles, coinsurance, and co-payments|
|Specified Low-Income Medicare Beneficiary (SLMB)||100-120% of FPL||Medicare Part B premiums|
|Qualifying Individual (QI)||120-135% of FPL||Medicare Part B premiums|
|Qualified Disabled and Working Individuals (QDWI)||under 200% of FPL||Medicare Part A premiums|
Medicare administers all MSPs, including the QMB program. The QMB program provides financial assistance to people who meet specific income and resource limits. It helps pay Medicare premiums and out-of-pocket costs.
If someone qualifies for the QMB program, they automatically qualify for Extra Help. This program helps with prescription drug costs.
People should contact their state’s Medicaid office to get information and find out if they are eligible to apply.