0865.000.00 Qualified Medicare Beneficiaries (QMB)

0865.035.05 Non-Spend Down May Become Spend Down When Adding QMB

When an individual becomes eligible for QMB coverage, the SMI premium is no longer an allowable deduction on the Medical Assistance budget. This may cause a non-spend down MA recipient to become a spend down recipient. Further, any medical expenses paid through the QMB program cannot be used to meet the claimant’s spend down. Therefore, the worker needs to explain this option to the claimant, and allow the claimant to make a choice as to which coverage s/he prefers.

These options are illustrated in the following example:

Ms. Crosby is a non-spend down MA recipient. She receives SSA of $450.80 which includes her SMI premium. Her net SSA check is $419.00. She is receiving Part A Medicare and is eligible for QMB on all other factors.

MA budget for: QMB individual non-QMB individual
Unearned income $450.80 $450.80
Standard deduction $ 20.00 $ 20.00
Adj. Gross Income $430.80 $430.80
SMI – $ 31.80
Non-spend down Limit $422.00 $399.00
Difference (spend down) $ 8.80 (non-spend down)

If she elects to receive QMB coverage, she will no longer have her SMI premium deducted from her MA budget, which will result in a spend down of $8.80. She will have to decide if she will incur at least $8.80 in applicable medical expenses each month, and could use the additional coverage the QMB card allows, or if it would be more beneficial to forgo the additional QMB coverage and not have to incur a set amount of medical expenses each month.