Medicare Savings Programs: QMB, SLMB, QI, QDWI and Extra Help

FEBRUARY 9, 2015 VOLUME 22 NUMBER 6

Health care programs for the elderly, the poor and the disabled can be complicated and confusing. We frequently find that clients are unclear about the differences — in eligibility and in coverage — between Medicare and Medicaid, for instance. Add in the fact that Arizona calls its Medicaid program AHCCCS (the Arizona Health Care Cost Containment System) but also ALTCS (the Arizona Long Term Care System) for some parts of the program, and the confusion begins to climb. Let us try to confuse things just a little bit more before (we hope) introducing some clarity.

First, the key distinctions between the two biggest government health care programs:

  • Medicare is a federal program, with very little state involvement (other than what we’ll be detailing in a moment). Medicaid is a joint federal-state program, administered by the individual states but funded mostly by the federal government.
  • Medicare beneficiaries are over age 65 OR they are receiving Social Security Disability Insurance payments. In other words, it is intended to cover the elderly and the disabled. Medicaid beneficiaries, on the other hand, may or may not be elderly or disabled — but they must be poor (with the state’s definition of “poor” quite variable).
  • Medicare covers (to a greater or lesser extent) inpatient hospital care, outpatient doctors’ visits and medications. Medicaid covers all medical expenses, including long-term care costs (an item that Medicare covers to a very limited extent).
  • Assets and income are irrelevant to Medicare coverage (except, of course, that if you are able to work you can’t be “disabled” in order to qualify before age 65). Medicaid pays close attention to income (whether earned from wages or received from investments, by gifts or otherwise) and assets (though there are differences state-to-state).
  • Medicare beneficiaries frequently have to pay co-payments (a share of the cost of a doctor’s visit, for instance), deductibles (the first $XX of a year’s medical costs, with XX being highly variable) and premiums (a flat amount for Medicare Part B coverage, for instance). Other than fairly nominal copayments, Medicaid beneficiaries usually do not have to pay any significant share of their medical costs; once eligibility is established, Medicaid picks up the entire cost.

Obviously, a person over age 65 might also have limited resources and income. A person with a disability might, as well. And a Medicare beneficiary might need medical care not covered by the program — like nursing care, for instance. There are five little-known programs available to help people who qualify for Medicare but need help with their premiums, deductibles or co-payments:

  • The Qualified Medicare Beneficiary (QMB) Program. The most generous of the four is the QMB program. It pays Medicare Part A and Part B premiums, and all co-payments and deductibles. QMB recipients also automatically qualify for “extra help” with their Medicare Part D premiums. In order to qualify, the applicant must have income of less than the federal poverty level (in 2015, that figure for a single person living in the continental U.S. is $11,770/year, or $981/month — for a married couple it is $15,930/year or $1,328/month) plus $20. In other words, a single person with income of less than $1,001/month will qualify. In addition, in many states (not including Arizona, which does not have an asset limitation for QMB benefits) the QMB applicant must have assets of less than $7,280 (for a single person) or $10,930 (for a married couple). Not counted among the assets in states which impose an asset limitation: the applicant’s home, car, household contents and a few other items (they use the same exclusions applied to the Supplemental Security Income (SSI) program).
  • The Special Low-Income Medicare Beneficiary (SLMB) Program. SLMB applicants can have up to 120% of the federal poverty income figures (plus the $20 that is disregarded — in other words, up to $1,197/month for a single person or $1,613 for a married couple), but are held to the same asset levels as those in the QMB program. Upon qualifying, the SLMB applicant will have Medicare Part B premiums paid — that will amount to a $104.90 monthly benefit for most Medicare recipients. SLMB beneficiaries also get “extra help” with their Part D premiums.
  • Qualifying Individuals (QI). A small group of people who do not qualify for any other Medicaid program might get help with their Medicare Part B premiums, if their income is between the $1,197 limit for a single person under SLMB and $1,345 (representing 135% of the federal poverty level, plus that ubiquitous $20). A married couple may have up to $1,813/month. As with QMB and SLMB, if you qualify for QI you also automatically get “extra help” with your Part D premiums.
  • Qualified Disabled and Working Individuals (QDWI). This one requires a little more explanation. For someone who once received Social Security Disability payments but returned to work, QDWI can pay the Medicare Part A premium (that’s $426/month in 2015). Income limits are up to 200% of the federal poverty guidelines (plus that $20), or $1,982 for a single person or $2,675 for a married couple. The most important thing about QDWI, though, is how few people will qualify — Arizona’s AHCCCS program notes that almost every QDWI recipient would also be eligible for the much more generous “Freedom to Work” program.
  • “Extra Help.” Programs that help pay co-payments and deductibles for Medicare’s Part D (drug) coverage go under the friendly name “extra help.” Any QMB, SLMB, QI, or SSI recipient will also get “extra help.” In some cases the program might reduce co-payment amounts but not eliminate them.

These programs can be bewilderingly complex, but they mean real benefits to recipients. Eligibility or the amount of benefit may also change year-to-year, as the beneficiary’s income goes up or down.

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18 Responses

  1. lorraine

     /  March 26, 2015

    considering moving to AZ but why does their Medicaid qmb income only 981.00 and other states follow medicare at 1001.00 a mo. in Idaho I qualify but in AZ I would not. Why don’t they follow national??

  2. Lorraine:
    Arizona does apply the same calculation — it’s just that the methodology (in Arizona and in other states) is confusing. The correct threshold number is $981 (in 2015); in addition, however, there is a $20 “disregard” applied. In other words, income of up to $1001 is permitted, but the limitation is usually expressed as $981. Remember, of course, that these figures are 2015 numbers — they’ll change again next year.

    Robert B. Fleming
    Fleming & Curti, PLC
    Tucson, Arizona

  3. Jim

     /  April 13, 2015

    Please explain what qualifies as “Income” in Arizona for these Medicare Savings Programs. Is it only “earned income” or does it include interest earned?

  4. Steve

     /  May 30, 2015

    Am on QMB in NY State. What’s the procedure to move to AZ without losing coverage?

  5. The Qualified Medicare Beneficiary (QMB) program is based on federal rules and definitions, but is administered by each state. If you are on QMB in one state and move to another, you will (unfortunately) have to apply and go through the new state’s eligibility review — which might be different, at least in small ways, from your original state.

    Robert B. Fleming
    Fleming & Curti, PLC
    Tucson, Arizona

  6. Jeff B.

     /  September 29, 2015

    I would like to transfer from slmb to slmb 2 or qmb (preferrably) here in Florida. It seems like noone knows how to do this. So what is the way to do this or “ways” – if there are more than one way. I’m looking for some guidance, please!

  7. QMB, SLMB and the other Medicare savings programs are income-dependent (and sometimes asset dependent). It’s not a matter of wanting to switch from one to the other so much as qualifying for another program.

    Most of the Medicare savings programs are administered by state Medicaid programs. Talk with your state’s Medicaid office about how to make an application for review of your income and/or assets.

    Good luck.

  8. Connie Merrell

     /  January 28, 2016

    When income is considered are medical expenses able to be deducted for the income that is considered?

    Thank You,
    Connie

  9. Connie:

    Generally, no. But we’re not familiar with the implementation of each of these programs in every state, and so there may be some circumstances in which medical expenses incurred or actually paid might reduce the income for eligibility calculations.

    Robert B. Fleming
    Fleming & Curti, PLC
    Tucson, Arizona

  10. TRUDY

     /  March 9, 2016

    I have severe heart and artery issues and am on oxygen. I am a disabled elderly person age 65. I am on the Qmb program. I am now in need of oral surgery. I have a constant infection. I have checked with 4 oral surgeons and they all want prepayments and cost is between 2,200.00 and more for 7 top teeth to be pulled with waiting lists 4 months out. My Dr. even referred me but now a matter of cost. I have no assets left to sell. Can you tell me if any part of the Qmb program would cover these costs? I do live in the State of Wisconsin

  11. Trudy:

    You should have a case worker through the state Medicaid program — they might be able to help. Other than that, we’d have to refer you to a Wisconsin attorney for information specific to state programs. Good luck, though.

  12. Laura

     /  July 15, 2016

    Our 29 yr old son is severely mentally and physically disabled. He is MAN in Alabama. We have a “second insurance” provided by my husband’s employer…my husband is retired. This second insurance does not pay for DME costs so now providers are telling me my son has to pay the deductibles and 20% not covered by Medicare. They say Medicaid won’t pay if second insurance won’t pay. Is this correct ND if so should we stop the second insurance?

  13. Laura:

    You might find a local expert on Medicare and supplements at your local Area Agency on Aging. Even though your son won’t be considered “aged,” you or your husband might (the usual age cutoff is 60, and sometimes 55 for some programs). AAoA offices are great on Medicare benefits. Failing that, look for an attorney in your community — one who is familiar with public benefits and aging issues.

    Good luck.

  14. Joann Dominguez

     /  August 8, 2016

    I am only trying to get extra help with or prescription drug plan program,which I understand by reading yor website that it is the QMB program. Right?. We reside in Arizona . What do I have to do to get this help?

  15. Here’s a link to the Arizona application, which is managed through Arizona’s Medicaid program, AHCCCS:
    https//www.azahcccs.gov/Members/Downloads/FDE-103.pdf

  16. Kim Jones

     /  August 30, 2016

    Hi,my husband and I both are disabled and we still have children at home.
    We qualified for prescription drug assistance,but nothing else. Why are dependents not considered when applying for QMB,or SLMB?
    Thanks!

  17. Lori

     /  December 16, 2016

    I waited an extra 10 yrs.before I finally got survivors benefits from my deceased husband’s benefits in May,2016. And,I had to literally keep sending emails,phonecalls,letters,for about 3 months to AHCCCS to let them know I had a slightly bigger income. Now,they’ve taken away the QMB benefits that I’ve been getting since 1997. And,they put me on SLMB ins.only for another 6 months. I’m a 60 yr.old disabled widow,which makes it hard to get Medicare supplemental,or,gap ins.before I’ll be 65 yrs.old,since it costs more than the survivor’s benefits I just started getting! I only get $1,058.00 a month,(which sounds good until you pay rent,bills,buy groceries with It!) And,now I’ve just found out I have a small mass in my left lung,too! Where do I go from here when I’ve only got Medicare now? I need a biopsy,tests,and,probably surgery,etc.,NOW!!

  18. Lori:

    QMB and SLMB are programs to help Medicare beneficiaries pay for the premiums, copayments and deductibles — they don’t make additional services available directly. If you move from QMB to SLMB, the only difference should be that you now have to pay your own co-payments and deductibles. You shouldn’t lose any coverage, just have to pay a small amount toward each prescription or office visit. Talk with your doctor’s office about scheduling the services you need.

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