The Qualified Medicare Beneficiary (QMB) is a state program that helps people with low income pay their Medicare costs.
QMB pays for Medicare Part A and Part B premiums, along with copayments, coinsurance, and deductibles.
Aside from QMB, three other state programs may help a person with limited means pay the costs associated with Medicare. The eligibility requirements differ in each program, so if someone does not qualify for QMB, they may qualify for one of the others.
Below, we discuss the benefits and eligibility requirements of the QMB program. Next, we examine the difference between original Medicare and Medicare Advantage with regard to QMB. Lastly, we look at the other three programs that help with Medicare costs.
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.
The QMB program is one of four state-run programs that help people who cannot afford their Medicare costs. Of the four programs, QMB is the one that offers the most assistance. A person who is enrolled in QMB is also enrolled in Medicaid.
The QMB program pays for the following:
- Part A monthly premiums
- Part B monthly premiums
- copayments
- coinsurance
- deductibles
In addition, QMB helps with prescription costs. The program does not allow drugstores to charge a person more than $3.90 for a prescription medication covered under Medicare Part D.
The income eligibility is the same in most states, apart from Alaska and Hawaii, where they may be higher.
The income eligibility requirements in most states for QMB are shown below:
An individual’s monthly income must be under $1,084.
A married couple’s monthly income must be under $1,457.
Other eligibility requirements involve countable resources, including bonds, stocks, and money in a savings or checking account. When Medicare adds up someone’s resources, they do not include:
- one car
- home
- furniture
- other household items
- burial plot
- up to $1,500 for burial expenses
Here are the resource eligibility requirements in most states for QMB:
An individual’s resource limits must be under $7,860.
A married couple’s resource limits must be under $11,800.
In 2017, more than 7.7 million people were enrolled in QMB. This means that more than 1 in 8 Medicare beneficiaries are in the program.
Whether a person is enrolled in original Medicare or Medicare Advantage, they are eligible for QMB if they meet the income and resource requirements.
Original Medicare consists of Part A, which is hospitalization insurance, and Part B, medical insurance.
Medicare Advantage, also known as Part C, is the alternative to original Medicare, so plans provide parts A and B benefits. Most of the plans also include the prescription drug coverage of Part D, along with extra benefits, such as dental care.
In regard to billing in the QMB program, there are several differences between original Medicare and Medicare Advantage.
Any Medicare provider cannot bill a person with original Medicare.
Any in-network provider cannot bill someone with an Advantage plan. In other words, to avoid getting bills, an individual who has an Advantage plan must choose in-network providers.
In addition to QMB, Medicare Savings Programs (MSPs) include the Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled and Working Individuals (QDWI) programs.
The income and resource requirements are standard in most states but vary in some states, including Alaska and Hawaii, where they may be higher. With this in mind, even if someone thinks they may not qualify for a program, they may wish to apply.
People who are interested in the programs can use this tool to find their local state and how to apply.
Below are the descriptions and eligibility requirements of each program.
Specified Low-Income Medicare Beneficiary program
The SLMB program helps people with Medicare Part A to pay their Part B monthly premiums. Eligibility requirements for income and resources in most states are the following:
- An individual’s monthly income must be under $1,296.
- A married couple’s monthly income must be under $1,744.
- An individual’s resources must be under $7,860.
- A married couple’s resources must be under $11,800.
Qualifying Individual program
Similar to the SLMB program, the QI program helps people with Medicare Part A to pay their Part B premiums. However, the income limits are higher.
A person must apply for the QI program every year. The program accepts applications on a first-come, first-served basis, but it gives priority to someone who is already enrolled.
Here are the eligibility requirements for income and resources in most states for QI:
- An individual’s monthly income must be under $1,456.
- A married couple’s monthly income must be under $1,960.
- An individual’s resources must be under $7,860.
- A married couple’s resources must be under $11,800.
Qualified Disabled and Working Individuals program
While the SLMB and QI programs help a person pay Part B premiums, the QDWI program helps someone pay Part A premiums. The following are the income and resource eligibility requirements in most states for QDWI:
- An individual’s monthly income must be under $4,339.
- A married couple’s monthly income must be under $5,833.
- An individual’s resources must be under $4,000.
- A married couple’s resources must be under $6,000.
Someone may quality for QDWI if one of the below conditions apply:
- They do not get medical assistance from their state.
- They are a working disabled person under age 65.
- They lost premium-free Part A when they went back to work.
- They meet the income and resource requirements of their state.
The QMB program and three other state programs provide help with Medicare costs for someone with limited means.
Of the four programs, QMB offers the most help because it pays Medicare Part A and Part B premiums, along with copayments, coinsurance, and deductibles.
People enrolled in original Medicare, as well as Medicare Advantage, are eligible for the QMB program if they meet the income and resource requirements. A person with an Advantage plan, and enrolled in a QMP program, must use in-network providers to avoid getting bills.