Qualified Medicare Beneficiaries

Description of QMB

Qualified Medicare Beneficiary (QMB) entitles low-income individuals to have Medicaid pay for their Medicare premiums, deductibles and coinsurance. An individual can have QMB only coverage, or QMB coverage and a full Medicaid coverage program. Recipients who are eligible for QMB coverage only are not eligible for any other Medicaid benefits.

QMB Eligibility

Qualified Medicare Beneficiary eligibility is determined by the Department of Children and Families. A recipient must have Medicare coverage in order to qualify for QMB coverage.

QMB Program Codes

The following program codes indicate that the recipient is a QMB and is not eligible for Medicaid services except for reimbursement of Medicare premiums, deductibles and coinsurance:

• QMB
• QMBR

QMB and Other Medicaid Eligibility

A recipient may be eligible for QMB and another aid category such as MI I, MW A, and MH H. They will have both QMB and the other aid category present in FMMIS. Someone who is eligible for Supplemental Security Income (MS aid category) and also eligible for Medicare is automatically considered QMB eligible with full Medicaid, even when the QMB category is not present in FMMIS.

Prohibition on Provider’s Billing

Providers may not bill recipients who are eligible as a QMB only or Medicaid and QMB for the Medicare coinsurance or deductible.

The Balanced Budget Act (BBA) of 1997 requires Medicare providers to consider whatever amount they are paid by Medicaid for Medicare cost sharing to be payment in full for any QMBs that they serve. Under the BBA, QMBs are relieved of the liability to pay any Medicare cost sharing to any Medicare providers or Medicare managed care entities, whether those providers participate in Medicaid or not. Providers or managed care entities are subject to sanctions if they charge recipients for any cost sharing at all.

Special Low Income Medicare Beneficiaries (SLMB) and Qualifying Individuals I (QI1)

Description of SLMB and QI1

Special Low Income Beneficiaries (SLMB) and Qualifying Individuals I (QI1) entitle individuals above a certain percentage of the federal poverty level to have Medicaid pay the Medicare Part B premiums. Recipients who are eligible for only SLMB or QI1 are not eligible for any other Medicaid benefit. Recipients may be eligible for SLMB and a full Medicaid coverage program for the same date of service. When the individual is enrolled in SLMB and another benefit program for the date(s) of service, the individual is eligible for the benefits available under the other benefit plan as well as payment of the Part B premium under SLMB.

Entitlement for the QI1 program is limited by the availability of the capped federal funding allocated to the state.

SLMB and QI1 Eligibility

Eligibility for these programs is determined by the Department of Children and Families. A recipient must be entitled to Medicare Part A to qualify for either of these programs.

SLMB and QI1 Program Codes

Individuals eligible for SLMB or QI1 will have the program codes SLMB or QI1. If the recipient has no other coverage than SLMB or QI1, they are eligible for payment of their Part B premium only, no other Medicaid benefits.

If the recipient has other Medicaid coverage in addition to SLMB and QI1, they are eligible for the benefits available under the other Medicaid coverage as well as payment of the Medicare Part B premium under QI1 or SLMB.

Reference

Florida Medicaid Provider General Handbook

Chapter 3 Qualified Medicare Beneficiaries (QMBs)