16 Del. Admin. Code § 17000-17300
A Qualified Medicare Beneficiary (QMB) is someone who is entitled to hospital insurance benefits under Part A Medicare and whose income does not exceed the Federal Poverty Level. All resources of the applicant and spouse are excluded when determining eligibility.
QMB's qualify for Medicaid to pay their Medicare Part A and B premiums, deductibles, and co-insurance expenses. They do not receive any Medicaid services.
This category of eligibles is mandated for coverage by the Medicare Catastrophic Coverage Act of 1988 (MCCA). Delaware Medicaid implemented the program effective 1/1/90. The eligibility and benefits are not retroactive.
The individual and his spouse, if married, must complete an application and provide the necessary verifications before a determination of eligibility can be made.
Applicants must be entitled to Medicare Part A.
A Qualified Medicare Beneficiary must have countable income that does not exceed 100% of the official poverty line. The revised poverty levels for QMB's with title II income (Social Security) will be effective April 1. If the QMB does not have title II income, the revised poverty levels will be effective February 1.
Social Security COLA increases will be excluded in determining the eligibility of recipients during the first three months of a calendar year.
The definition of income is the same definition used by the SSI program. In determining countable income take into account those income exclusions and disregards used by the SSI program. Eligibility for SSI (and QMB Program) is dependent in part upon the amount of income available, and since the program is need- oriented, those who have substantial income cannot receive benefits. Income is considered in the period in which it becomes available to meet the needs of the individual. Income includes anything received by the individual, in cash or in kind, that can be used to meet needs for food, clothing, or shelter.
Excluded income is an amount which is income by definition but does not count in determining eligibility because of Federal laws. The following list gives examples of items that are defined as income but are excluded for eligibility:
Impairment-related work expenses.
Interest and dividend income.
See Long Term Care Section for more examples of excluded income.
Some items that an individual receives are not income because they do not meet the definition of income. The following lists examples of items that are not income for SSI purposes (or QMB program):
In addition, Medicaid does not count AFDC/GA payments or payments made on behalf of foster children as income to the QMB's.
Gross income is income from all sources before any disregards, exemptions, or deductions such as taxes, health insurance premiums such as Medicare, life insurance premiums, loan payments, garnishments, credit union, alimony, child support (including court ordered), union dues, etc. have been applied.
Earned income is income that is received as a result of work activity. This includes wages, salaries, tips and commissions before taxes or other deductions such as pension fund, garnishment, or optional deductions such as insurance premiums or savings bonds or accounts.
A wage or salary paid under chapter 35 of title 42 of the U.S. Code, The Older Americans Act (for example, Senior Community Service Employment) is earned income. Anything provided under chapter 35 of title 42 other than a wage or salary (volunteer programs) is excluded from income. Also, payments for services performed in a sheltered workshop or work activities center program are earned income.
See the Long Term Care section for additional types of earned income.
A self-employment standard deduction is used to calculate self-employment income. The self-employment standard deduction is considered the cost to produce income. The self-employment standard deduction is a percentage that is determined annually and announced in the Cost-of-Living Adjustment (COLA) Administrative Notice each October.
To calculate self-employment income, use the gross proceeds and subtract the self- employment standard deduction. The result is the amount included in the individual's gross income. Standard earned income deductions are then applied to the individual's gross income.
To receive the self-employment standard deduction, the individual must provide verification that costs are incurred to produce the self-employment income. Verification can include, but is not limited to, tax records, ledgers, business records, receipts, check receipts, and business statements. The individual does not have to verify all business costs to receive the standard deduction.
If the individual does not claim or verify any costs to produce the self-employment income, the self-employment standard deduction will not be applied.
When the application of the standard deduction results in a finding of ineligibility, the applicant or recipient will be given an opportunity to show that actual self-employment expenses exceed the standard deduction. If the actual expenses exceed the standard deduction, they will be used to determine net income from self-employment.
9 DE Reg. 564 (10/01/05)
10 DE Reg. 143 (07/01/06)
Unearned income is income that is paid because of a legal or moral obligation rather than for work activity performed. It is all income that is not earned income. This includes Social Security, Railroad Retirement, pensions, benefits, alimony, child support and other types of payments. Interest and dividend income is excluded.
Rental income is unearned unless the rental proceeds are ordinary income of a trade or business being carried on by a self-employed individual, such as a real estate broker.
See the Long Term Care Section for more information on determining net rental income and more types of unearned income.
Since different exclusions apply to earned income than to unearned income, it is important to recognize the difference between them. In determining a QMB's countable income, deduct $20.00 from the gross income. This $20 exclusion is first applied to unearned income with the balance, if any, applied to the earned income. From earned income deduct the $20 if not already used, deduct $65 and 1/2 of the remainder. After the application of the deductions compare what is now the countable income to the income limits. There is only one $20.00 disregard from total combined income for a married couple. There is only one $65 and 1/2 remainder disregard from total combined earned income of the couple.
Verify the gross income of the ineligible spouse (the spouse who is not Medicare eligible). If that income is equal to or less than half the income limit for one QMB, then do not count any of the ineligible spouse's income toward the eligible spouse for the eligibility determination.
If none of the ineligible spouse's income is counted toward the Medicare spouse, the income limit for an individual is used to determine eligibility. If we must deem income from the ineligible spouse to the Medicare spouse, the income limit for a couple is used.
When determining the countable income of an applicant with children under age 18 and in the home, you can give a child's disregard which is 1/2 of the QMB's income limit for one. The child's disregard can only be applied to the ineligible spouse's income not the QMB's income and cannot be applied if the child has income that exceeds 1/2 of the QMB limit for one. Apply child's disregard before applying the $65 and 1/2 remainder disregard.
Please remember that we do not deem children's income to parents. We use a child's disregard to reduce the income we have to deem from the ineligible spouse to the eligible QMB.
QMB's coverage cannot be retroactive prior to 1/1/90. By Federal mandate QMB's are to become eligible the first day of the month after you determine them eligible. An individual may have dual eligibility as a QMB and as a Medicaid recipient. When authorizing coverage for an individual who is being terminated from Medicaid, you may begin coverage the month following the Medicaid termination.
Benefits are effective with the beginning of the month after the month in which you make a determination that an individual is a Qualified Medicare Beneficiary. For example, if you make a determination on August 15, benefits under this provision are effective beginning September 1.
Three month retroactive eligibility as provided for in 1902(a)(34) of the Social Security Act and in regulations at 42 CFR 435.914, is precluded under this provision. Thus, you may not make an individual eligible under this provision before the beginning of the month after the month in which the eligibility determination is made.
Medicaid will pay the:
| · | Part A hospital premium if a QMB has to pay for the premium. Most Medicare beneficiaries receive this coverage for free. |
| · | Part A or hospital deductible. |
| · | Part B premium. |
| · | The annual Part B deductible. |
| · | Coinsurance requirement of 20%. Physicians, labs, etc., would bill Medicare for 80% of the service and then bill Medicaid for 20% coinsurance or the remainder. |
We can only pay enrolled providers (those with a Medicaid contract). We cannot reimburse the recipients.
A redetermination of eligibility must be completed at least every 12 months. We will promptly redetermine eligibility when information is received about changes in circumstances that may affect eligibility.
Individuals who meet the eligibility requirements for Qualified Medicare Beneficiaries must be identified through the Medicaid identification card system as Qualified Medicare Beneficiaries. This is to alert providers that special coverage and reimbursement rules apply. Qualified Medicare Beneficiaries are Medicaid eligible and are entitled to the same rights and subject to responsibilities applicable to Medicaid eligibles (e.g., fair hearings and reporting requirements). For individuals eligible only as Qualified Medicare Beneficiaries, benefits are limited to medical assistance for Medicare cost-sharing expenses for services covered by Medicare.
Subject to state law, a provider has the right to accept a patient either as private pay only or as a QMB only. The provider must advise the patient, for payment purposes, how he will be accepted. Medicaid payment of Medicare deductible and coinsurance amounts may be made only to Medicaid participating providers. Medicaid may make a payment even though a Medicare service is not covered by Medicaid in the State plan. The claim may not be rejected on the basis that the Medicare service is not covered by Medicaid or that the provider accepts the patient as a Qualified Medicare Beneficiary only. The actual payment made by Medicaid is payment in full for Medicare deductibles and coinsurance. The provider is restricted from seeking to collect any amount from the QMB for Medicare deductibles or co-insurance even if Medicaid's payment is less than the Medicare deductible and co-insurance.
16 Del. Admin. Code § 17000-17300