Medicaid QMB (Qualified Medicare Beneficiary) Cost Assistance

• by Christian Worstell
• August 10, 2023
• Reviewed by John Krahnert

QMB stands for “Qualified Medicare Beneficiary” and is a cost assistance program designed to help individuals who are eligible for both Medicare and Medicaid, a circumstance that is known as “dual eligibility.”

The QMB program helps pay for the full cost of Medicare Part A and Part B premiums along with complete coverage of deductibles, copayments and coinsurance. QMB offers the most comprehensive coverage of the programs available to dual-eligible beneficiaries.

QMB enrollees face no out-of-pocket costs for care that is covered by Medicare Part A or Part B that is administered at a Medicare-approved facility by an approved provider. States do have the right to impose their own laws related to QMB that may override federal regulations, but any costs to the beneficiary would be minimal.

How does Medicaid QMB work?

In addition to covering Medicare premiums for eligible QMB recipients, one of the benefits of the QMB program is having protection from improper billing. Improper billing refers to when health care providers inappropriately bill a beneficiary for deductibles, copayments or coinsurance.

Federal law prohibits providers from billing beneficiaries enrolled in the QMB program for any such costs. This law even pertains to non-participating providers, who are allowed to charge other Medicare beneficiaries more for care. 

QMB beneficiaries who are enrolled in Medicare Advantage plans are also protected from any cost-sharing requirements when receiving covered care from in-network providers. 

The QMB improper billing protection even extends to health care providers who do not accept Medicaid. That means QMB members may receive care from a provider who does not accept Medicaid and still receive protection from deductibles, copayments and coinsurance. 

Providers who do not adhere to QMB improper payment protection guidelines may be subject to penalties. 

Who is eligible for QMB?

You must be eligible for both Medicare and Medicaid to be eligible for QMB benefits. While Medicare’s eligibility requirements are federally mandated, each state may set its own qualifying restrictions for Medicaid. 

You must also meet the QMB income and resource limits in 2023:

• The individual monthly income limit is $1,235
• Married couples may have a monthly income of no more than $1,663
• The value of an individual’s combined resources are capped at $9,090
• Married couples may have combined resources of up to $13,630

To apply for the QMB program, contact your state Medicaid program. Please not that if your income or financial resources are close to the totals listed above, you should still apply, as you may potentially be eligible.

What are other Medicare and Medicaid assistance programs?

QMB is not the only program available to dual-eligible beneficiaries. Others include:

• The Specified Low-Income Medicare Beneficiary (SLMB) program covers Medicare Part B premiums.
  
  
• The Qualified Disabled Working Individual (QDWI) program allows individuals who lost Medicare Part A benefits after returning to work can buy back these benefits under this program.

Dual-eligible beneficiaries may also enroll in a Dual-eligible Special Needs Plan (D-SNP). This is a particular type of Medicare Advantage plan with a benefits package that is tailored to the needs of those with the limited income and resources common among Medicaid recipients. 

Special Needs Plans are sold by private insurance companies, so contact a licensed insurance agent for additional information. You can also compare plans online to see if there are Medicare SNPs available where you live.

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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