Managing healthcare costs can be overwhelming, especially for those with limited income. The Qualified Medicare Beneficiary (QMB) Program is designed to ease this burden by covering essential Medicare expenses and protecting beneficiaries from improper billing.
In this article, we explore the benefits of the QMB Program, eligibility requirements, and steps to apply, ensuring you have the knowledge to take control of your healthcare finances.
If you qualify for the QMB program:
The Qualified Medicare Beneficiary (QMB) Program delivers much-needed relief to low-income Medicare recipients. This government plan pays Medicare Part A premiums, Medicare Part B premiums, deductibles, coinsurance, and copayments (for services and items Medicare covers). Those receiving retirement benefits access essential healthcare services without significant out-of-pocket expenses.
Premium: The monthly amount you pay for coverage, whether you receive services or not.
Deductible: The amount you pay for covered services and items each year before Medicare or your plan kicks in.
Coinsurance: A percentage of the cost that you pay.
Copayment: A fixed amount you pay for a Medicare-covered service (ie. $20).
The QMB plan simplifies getting the medical care you need without worrying about how to pay for it. This support streamlines your healthcare experience and encourages you to seek medical services regularly, leading to better health outcomes.
The federal government determines financial limits annually based on the Federal Poverty Guidelines. To qualify, you must meet specific financial conditions, which can sometimes lead to confusion about billing rules.
Income limits are the maximum amount you can earn each month to be eligible.
Resource limits are the maximum value of assets you can own, which can include money in a checking, savings, or retirement account, stocks, and bonds. (Note that states don't count your home, one car, burial plot, or up to $1,500 for burial expenses if you have put that money aside, as well as furniture and other household and personal items.)
We recommend you verify the income and resource limits with your state Medicaid office, as some states have higher limits or waive the asset test.
You'll apply for Medicare Savings Programs through your state Medicaid agency. When you apply, your state determines which Medicare savings program(s) you might qualify for.
If you qualify for both Medicaid and QMB, you're considered "dually eligible," which can provide extra benefits like dental, vision, and hearing care.
The eligibility categories for dually eligible individuals include QMB-Only and QMB-Plus, each providing specific levels of assistance with Medicare Parts A and B premiums and cost-sharing.
QMB-Only individuals are eligible for Medicare Part A, have incomes up to 100% of the federal poverty level (FPL), and have limited resources but do not qualify for full Medicaid benefits. Medicaid covers their Medicare premiums and cost-sharing; providers cannot bill QMB-Only beneficiaries for these costs.
QMB-Plus individuals meet QMB eligibility criteria and also qualify for full Medicaid benefits under a separate state plan category. They receive assistance with Medicare premiums and cost-sharing, along with full Medicaid benefits.
States can adopt policies to limit Medicaid payments for Medicare cost-sharing to the lesser of the Medicare cost-sharing amount or the difference between the Medicare payment and Medicaid rate. Both groups are protected from billing for Medicare cost-sharing amounts, ensuring greater financial relief for beneficiaries.
If you're in the Medicare Savings QMB Program, it's against the law for Medicare providers to charge you for items and services Medicare covers, including deductibles, coinsurance, and copayments.
If you get a bill for Medicare-covered items, tell your provider that you're in the QMB program and can't be charged for Medicare deductibles, coinsurance, and copayments.
You can prove your QMB status by showing your Medicare card, which notes your QMB eligibility, or providing documentation from your state Medicaid office confirming your enrollment in the program. Additionally, Medicare providers can verify your QMB status through their Medicare billing system.
If you already paid for services and items Medicare covers, you have the right to a refund. Contact your State Medical Assistance (Medicaid) office to find out how to get a refund.
Contact 1-800-MEDICARE to verify your enrollment in the QMB Program. They can assist in notifying your provider to cease billing you and request a refund for any payments you've already made.
Submit a complaint to the Consumer Financial Protection Bureau by visiting their website at consumerfinance.gov/complaint or calling 1-855-411-2372 toll-free. They will forward your complaint to the debt collection agency and assist you in getting a response.
fIn addition to the Qualified Medicare Beneficiary program, there are three other Medicare Savings Programs (MSPs) designed to help individuals with limited income and resources manage Medicare-related costs:
The QMB Program offers financial support to low-income Medicare beneficiaries, making sure they have access to necessary healthcare without added financial stress. By simplifying healthcare costs and providing legal protections against improper billing, QMB empowers eligible individuals to prioritize their health. If you think you qualify, take the necessary steps to apply and safeguard your financial and medical well-being.
