0865.000.00 Qualified Medicare Beneficiaries (QMB)

0865.035.15 Budgeting Procedure When MA and QMB Applications Are Approved in the Same Month

If a claimant applies for MA and QMB and is approved for both in the same month, the SMI premium can only be considered as a budget deduction for the months they will not receive QMB. If this deduction would have allowed the claimant to be a non-spend down for MA, the claimant may be a spend down when QMB is approved, as this deduction cannot be considered. If a QMB approval results in the claimant no longer being eligible for Medical Assistance on a non-spend down basis, the case must be changed to spend down effective the first day of the month following the month the QMB approval is entered in the IMU5 system.

When the MA and QMB applications are approved at the same time, the SMI premium can only be used as a deduction for the months before QMB eligibility begins.

REMEMBER: QMB eligibility can never start in the month of application. It must begin the month AFTER the determination is made.

The following example illustrates how the Medicare premium deductions are used for this initial approval:

Ms. Trout applied for MA and QMB on April 1, 2004. She is ready to be approved for both programs on May 10, 2004. Her only income consists of $784.60 from SSA which includes the SMI premium of $66.60. Her Medicaid coverage through the Medical Assistance program begins on April 1, 2004, and her QMB coverage begins on June 1, 2004. Income figures are as follows:

  April and May
MA eligibility begins
QMB eligibility begins
SSA $784.60 $784.60
SMI (-) $ 66.60 no deduction
STD (-) $ 20.00 $ 20.00
NET $698.00 $764.00
Non-spend down Limit $699.00 $699.00
  non-spend down spend down ($65.00)

In the above situation, April and May are the only months Ms. Trout will be paying her own SMI premium, based on her QMB approval. (Remember: QMB eligibility begins the month after the month of approval).

On May 10 enter the case in the IMU5 system as a non-spend down case without QMB. On May 11 change the case to spend down effective June 1, 2004 and enter a “Y” in field 13M1 and enter the QMB eligibility date in field 13M2.