0865.000.00 Qualified Medicare Beneficiaries (QMB)

0865.035.10 Special Procedures for QMB/Spend Down Combination Approvals

Some specialized procedures are necessary when processing QMB cases in conjunction with spend down. Examples of these procedures follow:

If an active QMB recipient becomes spend down, the QMB coverage does not terminate at the end of the month as the MA coverage does. The QMB coverage carries over from one month to the next and is not interrupted unless some other factor causes ineligibility. When a QMB-only recipient becomes eligible for MA spend down, do not close the QMB case. Approve the MA case and show QMB eligibility with a “Y” indicator in field 13M1 along with the original QMB eligibility date in field 13M2. (IMU5 shows the indicator and date to be re-entered.) On the date the transaction is processed, the system automatically closes the QMB-only case. QMB coverage is continued through the MA spend down case with the QMB indicator.

On new spend down approvals, the caseworker must send an approval letter (IM-32SPDN) notifying the claimant they have been approved for spend down, but full Medicaid coverage will not begin until the spend down is met. Further, the worker should include a note to the claimant on the IM-32 which states, “Your QMB coverage continues unless you are otherwise notified. It is not interrupted by your spend down coverage ending.” The letter will inform the claimant of the spend down amount and the months for which they can receive coverage by meeting spend down. If the worker has already received bills to meet spend down for some of the months, the letter includes the dates of coverage for those months.