If you’re a Medicare beneficiary, you know that healthcare costs can quickly add up. These costs are especially noticeable when you’re on a fixed income. If you are a senior with a monthly income and total assets that are under the limit, you might be eligible for a Qualified Medicare Beneficiary program, or QMB. Below, we’ll explain all you need to know about what the QMB program pays for, who’s eligible, and how to sign up.
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What Is QMB?
The Qualified Medicare Beneficiary (QMB) program is a type of Medicare Savings Program (MSP). The QMB program allows beneficiaries to receive financial help from their state of residence with the costs of Medicare premiums and more.
A Qualified Medicare beneficiary gets government help to cover healthcare costs like deductibles, premiums, and copays. Recipients must meet all criteria to qualify for the program assistance.
- The Medicare Part A monthly premium (if applicable)
- The Medicare Part B monthly premium and annual deductible
- Coinsurance and deductibles for healthcare services through Medicare Part A and Part B
If you’re in a QMB program, you also automatically qualify for the Extra Help program, which helps pay for prescription drugs.
QMB Income Limits 2022
To be eligible for a QMB program, you must qualify for Medicare Part A. Your monthly income must be at or below $1,153 as an individual and $1,526 as a married couple. Your resources (money in checking and/or savings accounts, stocks, and bonds) must not total more than $8,400 as an individual or $12,600 as a married couple.
Keep in mind that income and resource requirements for the QMB program are subject to increase each year. Thus, members must go through a redetermination to continue receiving benefits for the following year. This process includes providing your local Medicaid office with updated information about your monthly income and total resources.
If someone doesn’t have Medicare Part A but is eligible, they can choose to sign up anytime throughout the year. Once they sign up for Medicare Part A, they can proceed to apply for the QMB program. If they need to pay a premium for Medicare Part A, the QMB program can cover it.
State-Specific Name Conventions for QMBs
In North Carolina, QMB is called MQB. If you live in Nebraska, Federal QMB is replaced with full Medicaid.
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How to Apply for a QMB Program
Seniors submitting a QMB application must contact their state’s Medicaid office. If your income is higher than the QMB requirements, you should still reach out to determine eligibility.
Each state’s Medicaid program pays the Medicare cost-sharing for QMB program members. Anyone who qualifies for the QMB program doesn’t have to pay for Medicare cost-sharing and can’t be charged by their healthcare providers.
QMB Plus
If an individual is considered a QMB Plus, they meet all criteria for the QMB program but also meet all financial requirements to receive full Medicaid services. These enrollees can receive benefits through the QMB program as well as their state’s health plan.
The first step in enrollment for the QMB program is to find out if you’re eligible. A quick and easy way to do this is to call your local Medicaid office. The next step is to complete an application. You can request for Medicaid to provide you with an application form or locate a QMB program application from your state online.
Billing Requirements for QMB
Providers can’t bill QMB members for their deductibles, coinsurance, and copayments because the state Medicaid programs cover these costs. There are instances in which states may limit the amount they pay healthcare providers for Medicare cost-sharing.
Even if a state limits the amount they’ll pay a provider, QMB members still don’t have to pay Medicare providers for their healthcare costs, and it’s against the law for a provider to ask them to pay.
If Your Provider Charges You and You’re in the QMB Program
Inform who is requesting payment that you’re in the QMB program. If you’ve already paid, you’re entitled to a refund.
To ensure this does not happen, show your QMB card or Medicare and Medicaid card to your providers each time you receive care. Your Medicare Summary Notice (MSN) can also prove that you’re in the QMB program. You can access your MSN electronically through your MyMedicare.gov account.
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If a provider continues to bill you, call Medicare’s toll-free number. They will confirm your QMB status and request cessation of billing and/or refunds from your provider(s). In the case that debt collectors wrongly pursue payment, you can submit a complaint to the Consumer Financial Protection Bureau (CFPB) online or via telephone.
Is QMB Full Medicaid?
No, QMB and Medicaid are two different programs. If you are part of a QMB program, you will not receive regular Medicaid benefits. The Medicaid program covers out-of-pocket Medicare costs for beneficiaries of the QMB program. Deductible or coinsurance payments for services covered by your State Plan are not limited by Medicaid.
How Does QMB Work With Medicare Advantage Plans?
If you’re currently in the QMB program, you can enroll in a Medicare Advantage plan. There are unique plans for those with Medicare and Medicaid. A Medicare Advantage Special Needs Plan for dual-eligible individuals could be a fantastic option. Generally, there is a premium for the plan, but the Medicaid program will pay that premium.
Many people choose this extra coverage because it provides routine dental and vision care, and some come with a gym membership. While not every policy has these benefits, there may be one available in your area!
Do I Need to Enroll in a QMB Program if I Have Medigap?
Medigap coverage isn’t necessary for anyone in the QMB program. This program helps you avoid the need for a Medigap plan by assisting in coverage for copays, premiums, and deductibles. Those that don’t qualify for the QMB program may find that a Medicare Supplement (Medigap) plan helps make their healthcare costs much more predictable.
Can a Medicare Provider Refuse a QMB Patient?
According to the regulations set out by the Centers for Medicare & Medicaid Services (CMS), Medicare providers cannot discriminate against patients based on source of payment, which includes QMB and other assistance programs.
Does Social Security Count as Income for QMB?
Your Social Security Income (SSI) payments will count as income when applying for QMB. Seniors must take this into consideration and fall within the appropriate thresholds in order to qualify for the program.
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How to Get Additional Coverage with Your QMB Program
If you qualify for a QMB program, you'll save money on out-of-pocket Medicare costs. For further savings, you can add supplemental coverage to your Original Medicare.
Pairing a QMB and Medicare Advantage Special Needs Plan is a great way to protect yourself from unexpected health costs. It also provides extra benefits at an affordable price.
Call the number above to get rate quotes for plans in your area that work with your QMB eligibility. Another option is to fill out our form to compare rates. An agent will reach out to you with quotes from top-rated carriers.
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Sources:
MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.
- Medicare Savings Programs, Medicare. Accessed April, 2023 .
https://www.medicare.gov/medicare-savings-programs - Qualified Medicare Beneficiary (QMB) Program, CMS. Accessed September 2023.
https://www.cms.gov/medicare/medicaid-coordination/qualified-medicare-beneficiary-program
Hi Im in Illinois,and receive with my wife SSDI as only income 2013$.We have both QMB,but in Februrary they kick me out and March they put me on again ,now in April same thing.Prescription is still Ok Im paying copay 1.35$.Any help.Thank you.
Adam, this could be happening if you have experienced a change in income month over month. Do you work a part-time job or receive additional income?
Yes they kicked me off because they said I make 1785 a month can they do this.
Hi, JE, Have a Humana MA HMO plan and the hospitalist sent me to an out of network physician without a referral. Humana has denied payment for no referral and no out of network benefits. The Medicaid plan has denied the service since Humana did as not authorized. Does the out of network provider have to cancel the bill since they didn’t tell me they were out of network? Thanks.
Unfortunately, when you enroll in an HMO plan it is your responsibility to ensure providers you use for coverage are in network for your plan. Since you have visited the out-of-network physician, the bill cannot be erased and will likely be your responsibility to pay.
Hi, I’m in Ohio, and recieve SSDI as my only income. I have no resources. At my Medicaid redeterminaton in October (2021) for 2022, I was found to be QMB. However, I’m confused by the income limits as I’m finding different answers everywhere. When I contacted Medicaid, I was told I was QMB, and that they cover part B. Can you help me to understand?
Hi Pat, thank you for reaching out! Since you have been found a Qualified Medicare Beneficiary, this means that you will be reimbursed the Medicare Part A and Part B premium through your Social Security check each month as well as deductibles, coinsurance, and copayments.
I only get Social Security 2267 a month I live in Georgia qualified for the extra help last two years my husband died 2 years ago and that’s why I qualify this year They say I don’t qualify we just redid the application we got a raise on Social Security and that’s been The only increase I’ve had
I don’t understand why
it was helping pay my Medicare premiums and I’ll I have is Social Security I was very hard to pay the house payment and all the utilities and Live
im am on QMB establised member an medicare i got a,yearlletter on qmb application online website type my address ive had years webtite says my address iinvalid im affraiq im going to lose my qmb
Hi Jessie – you should contact Medicare directly about this.
Hi Lindsay, what if I already have Medicare A & B and plan G supplement. And I wish to have my part B premiums covered through a state/federal program, but would qualify for QMB due to my income. Will I still be able to retain my Supplement Plan coverage under QMB, would only SLMB allow me to retain my Medigap coverage?
Since QMB is state-specific under Medicaid rules, it would depend on what state you live in. Some states will allow you to keep your Medigap plan even if you’re eligible for QMB, while others do not. I would contact your local Medicaid office to find out if you can keep your Medigap plan.
I’m in the state of Georgia and have Q.M.B. does it pay for doctor visits at a general practice ! Only get an automated person when calling to get this info .
Hi Lynn! Yes, it should cover a doctor’s visit.
Hi, I might be moving to Oregon from Idaho. I do qualify for the highest level of QMB and extra help in Oregon. My question is, would having extra help and being a Qualified Medicare Beneficiary, pay for my full part B premium of a. Medicare advantage PPO?
Hi Matthew! The premium for Part B is for Part B only. The premium for a Medicare Advantage plan is in addition to the Part B premium. I just wanted to clarify that because “pay for my full Part B premium of a Medicare Advantage PPO” is not correct. QMB only covers costs under Part A & Part B, it will not cover the premium for Medicare Advantage.
Hi Lindsay! I was seeing my Medicare primary care physician for a regular 4 month visit but this last time she coded the visit differently so that Medicare and Medicaid would not cover it. I am in QMB and she knew this as I’ve been going to this doctor the last 2 years. I have been receiving billing statements to pay 178$ for this particular visit. I have tried to tell the doctor and office that I am QMB but she wont change the coding and I continue to get billed. I’ve never been charged doctors visits since being disabled 5 years ago and have been on QMB the entire time as now. There is no reason for her to code this visit any differently as the others. Should they be sending me a bill?
Hi Janet! No, they absolutely should not be sending you a bill. I would call your local Medicaid office since they are the ones who handle your QMB. They should be able to help you get this corrected.
Good afternoon,
If a provider accepts Medicare but cannot be credentialed as a Medicaid provider for therapy services and the patient has QMB, can the patient sign an ABN or do we have to adjustment the balance after Medicare pays?
This is a tricky one. I would think you would have to adjust the balance after Medicare pays their portion. You cannot bill a QMB beneficiary. I would reach out to your local Medicaid office to find out for sure.
Hi Lindsay
I’m on QMB. My mother passed and I was the beneficiary amount is over the limit for checking and savings, but can I still claim the money and keep my benefits?
Hi Rebecca! This is something you would have to talk to your local Medicaid office since the rules differ from state to state. Your local Medicaid is what manages your QMB. Some states allow you to be a little over the limit without losing benefits. There are also other Medicare Savings Programs you may qualify for still if you’re over the QMB income limit.
I’ve been searching for few hours here to try to find the answer myself and I can’t. Thanks in advance for your help, Lindsay. I have 2 very quick questions What’s required to be provided for proof of income – tax returns? I feel comfortable doing that – no problem. What’s required to provided though for proof of assets in a bank account? I really don’t feel comfortable providing my actual bank account number and/or complete statement to them. Thanks again for your help.
Hi Janeil! For proof of income, your tax return will do. To verify assets, you’ll have to provide documentation for any checking, savings, money market, credit union, life insurance policies, deeds or appraisals for one’s home and other real estate, copies of stocks and bonds, annuities, IRAs, and 401k. You will need to provide complete statements in order for them to verify your assets.
i currently have medicare and pay 148 a month but was told by the caseworker for my great granddaughter whom i have custody of say that i qualify for the qmb plan
Hi Sylvia! You can apply for a QMB through your local Medicaid office.
If my son earns $944 per month SSDisability, how much can he earn per month in a part-time job? I know the limit is $1084. IS there a formula to use or is it strictly !084-944=140 dollars.
Also, he is on a Medicare Advantage plan, and he usually pays $25 per visit but he is a QMB. Should he not be paying that office visit amount? I know that I had shown his Medicaid card at one point, but was unaware that it may pay that $25.
Hi Nancy! Anything over the income limit earned from a part-time job would most likely make him ineligible for QMB. However, there are other Medicare Savings Programs he may still be eligible for as long as his income does not go over the limit set in place by his state for that program. Regarding paying a copay, no, your son should not have to pay a copay if he has QMB. Inform his physician that he has QMB and that you’re entitled to a refund. If they continue to bill you, call Medicare directly. You can file a complaint.
My dad had QMB with help for prescriptions he did not use and Humana Advantage plan. From my understanding Medicaid paid for the Medicare cost each month for part A or B ( not sure which or both).
I was curious about a bill after reviewing the Humana Advantage plan EOB for an ambulance service and share of cost. I called and was told they sent the bill to Medicaid for payment. My dad passed away. Do I need to be concerned about the ambulance bill that Medicaid paid and also the monthly payments Medicaid paid each month for his Medicare A or B ? Will they ask for recovery of what was paid?
Note: He was hospitalized and I see payments by his Humana Advantage Plan EOB and everything being paid by his plan.
Thanks
Hi JM. So sorry to hear about the passing of your father. As long as Social Security has been notified of his passing, there is nothing you need to do regarding Medicaid or Medicare for him. His Medicare Advantage plan & Medicaid should’ve taken care of any ambulance bills. You are not responsible for any medical bills left unpaid. Please don’t hesitate to reach out if you have any additional questions.