QMB, SLMB, QI-1, and QDWI Programs: Help with Medicare Premiums, Deductibles
by: Northwest Health Law Advocates
Are you eligible for help in paying for Medicare premiums and deductibles?
Some people who get Medicare can qualify for help in paying the premiums, deductibles, and cost-sharing in the Medicare program. Qualifying for this help depends on your income and resources. If you have low income, you may be a Qualified Medicare Beneficiary (QMB), a Special Low Income Medicare Beneficiary (SLMB), a beneficiary of the Qualified Individual (QI-1) program, or a Qualified Disabled Working Individual (QDWI). These are called Medicare Savings Programs (MSP). There are also State Funded Medicare Buy-In Programs for those not eligible for the MSP.
Do I have to be 65 years old?
No. A disabled person under age 65 who is eligible for Medicare may be eligible for these programs.
What are the benefits?
For a Qualified Medicare Beneficiary (QMB), most Medicare premiums, deductibles, co-payments and coinsurance are paid by the state (subject to certain restrictions). QMB will pay for Medicare Parts A and B. QMB pays premiums starting the month after you are certified. As of January 1, 2007, Washington State will no longer pay premiums for Medicare Part C (?Medicare Advantage?) enrollees except for certain QMB beneficiaries who also get full Medicaid. However, for other QMB beneficiaries, the state will pay Part C deductibles, co-payments, and coinsurance.
The QMB program does not pay for Medicare Part D prescription drug coverage. However, qualifying as a QMB reduces the cost of Part D because QMBs are automatically eligible for Part D?s Low-Income Subsidy. The subsidy entitles QMBs to enroll in certain Part D Plans with no premiums, deductibles or gaps in coverage, and low copayments. (Enrollment in a Part D Plan is handled through federal Medicare, not the state Medicaid agency.)
A Special Low Income Medicare Beneficiary (SLMB) gets Medicare Part B premiums paid by the state. SLMB pays premiums up to three months before the date of your certification.
The SLMB program does not pay for Medicare Part D prescription drug coverage. However, qualifying as an SLMB reduces the cost of Part D because SLMBs are automatically eligible for Part D?s Low-Income Subsidy. The subsidy entitles SLMBs to enroll in certain Part D Plans with no premiums, deductibles or gaps in coverage, and low copayments. (Enrollment in a Part D Plan is handled through federal Medicare, not the state Medicaid agency.)
A beneficiary of the Qualified Individual (QI-1) program gets Medicare Part B premiums paid by the state unless the client already receives Medicaid. The QI-1 program only has a certain number of spaces available each year. Once the spaces are taken, no new clients will be added, even if they are qualified. QI-1 pays premiums up to three months before the date of your certification. Qualifying as a QI-1 reduces the cost of Part D because QI-1s are automatically eligible for Part D?s Low-Income Subsidy. The subsidy entitles QI-1s to enroll in certain Part D Plans with no premiums, deductibles or gaps in coverage, and low copayments. (Enrollment in a Part D Plan is handled through federal Medicare, not the state Medicaid agency.)
A beneficiary of the Qualified Disabled Working Individual (QDWI) program gets Medicare Part A premiums paid by the state unless the client already receives or starts to receive Medicaid. QDWI pays premiums up to three months before the date of your certification.
The State-funded Medicare Buy-in program beneficiary gets Medicare Part B premiums paid by the state, and gets Medicare Parts A and B co-insurance, deductions, and co-payments paid up to the cost sharing rate.
These programs do not pay for items which Medicare does not cover. The state?s medical assistance program (Medicaid) may pay for such non-Medicare covered services. You may ask your local Department of Social and Health Services (DSHS) when you apply for QMB or SLMB if you are eligible for the Medicaid program. This is called dual eligibility.
Who qualifies as a QMB?
To qualify as a QMB, your income must be at or below 100% of the federal poverty level (FPL). The income guidelines based on the federal poverty level, change once a year in April. Currently, 100% of the FPL is $851 for one person and $1141 for a couple. Countable resources must be less than $4,000 for a single person and $6,000 for a couple.
Who qualifies as an SLMB?
To qualify as an SLMB, the income limit is 120% of FPL. Currently, 120% of the FPL is $1,021 for one person and $1,369 for a couple. The resource requirements are the same as QMB. Countable resources must be less than $4,000 for a single person and $6,000 for a couple.
Who qualifies for QI-1?
To qualify for QI-1, the income limit is 135% of FPL. Currently, 100% of FPL is $1,149 for an individual and $1,541 for a couple. 135% of FPL is $1149 for an individual and $1541 for a couple. Countable resources must be less than $4,000 for a single person and $6,000 for a couple.
Who qualifies for QDWI?
To qualify for QDWI, your income must be no more than 200% of FPL. Currently, 200% of FPL is $1702 for an individual and $2282 for a couple. A client must be working to qualify for QDWI. Countable resources must be less than $4,000 for a single person and $6,000 for a couple.
Who qualifies for state-funded Medicare buy-in programs?
If you do not qualify for one of the above Medicare buy-in programs and you receive Medicaid, you may qualify for the state funded Medicare buy-in program. There is no income limit on this program.
What counts as income?
Income is usually money, either earned through working, or unearned, such as Social Security or pensions. Income also includes interest earned on savings accounts or certificates of deposit, as well as dividends on stocks. Income does not include cash or in-kind federal, state, or local government assistance for medical care or for needs other than food, shelter, or clothing.
What counts as a resource?
Cash, liquid assets, and real or personal property are all resources. The following resources are not counted when figuring eligibility:
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Your home and surrounding land, household goods and personal effects, life insurance with cash value less than $1,500, burial spaces, and burial funds of less than $1,500.
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A vehicle of any value is not counted if it is necessary for employment, getting to medical treatment, modified for handicapped use, or necessary for transportation due to climate, terrain or distance. If a vehicle cannot be excluded based on these exceptions, then it can be excluded if its current market value is $5,000 or less. A vehicle can be anything used to transport people on land, by air, or by water.
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Trust or restricted Indian property.
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Up to $6,000 in land or personal property used to produce goods and services essential to everyday living.
How do I apply?
You can apply at the local Department of Social and Health Services (DSHS) office. DSHS is listed in the telephone directory under the State of Washington listings. If DSHS decides that you are not eligible and you disagree, you have the right to appeal the decision by asking for a fair hearing. To request a fair hearing, write to the Office of Administrative Hearings at P.O. Box 42489, Olympia, Washington 98504-2489. To find out about fair hearings, see our publication Representing Yourself at a Fair Hearing.
This publication is a combined effort of the Northwest Health Law Advocates and Northwest Justice Project.
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This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of the date of its printing, September 2007.
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