What's the difference between QMB and QMB+?

As of 2023, more than 8 million Medicare beneficiaries were enrolled in the Qualified Medicare Beneficiary (QMB) program. Understanding what's the difference between QMB and QMB+ is crucial for low-income seniors seeking comprehensive healthcare assistance. These programs, both subsets of Medicare Savings Programs, offer distinct levels of coverage that can significantly impact your out-of-pocket costs.

Quick Summary

QMB, or Qualified Medicare Beneficiary, is a Medicare Savings Program that covers Medicare premiums, deductibles, and coinsurance for low-income individuals. QMB+, or Qualified Medicare Beneficiary Plus, is the designation for someone who meets QMB qualifications but also receives full Medicaid benefits, which includes additional services not covered by Medicare, like dental or vision.

Key Points

• QMB Covers Medicare Costs: {Link: Medicaid.gov https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/cost-sharing-chart.pdf}

• QMB+ Adds Full Medicaid: QMB+ is for individuals who qualify for QMB benefits and also for full Medicaid, granting access to more extensive coverage.

• QMB is Partial, QMB+ is Comprehensive: QMB covers only Medicare cost-sharing, while QMB+ adds full state Medicaid benefits for a wider range of services.

• Providers Cannot Bill QMB Patients: Federal law prohibits Medicare providers from billing QMB-enrolled individuals for Medicare-covered services.

• Apply Through State Medicaid: Apply through your state's Medicaid office to determine eligibility for QMB, QMB+, or another Medicare Savings Program.

• QMB Automatically Grants Extra Help: QMB enrollees automatically qualify for Extra Help for Medicare Part D prescription drug costs.

• Financial Limits Apply: Both programs have income and resource limits, though disregards mean it's worth applying even if you think you might be over the limit.

Demystifying Medicare and Medicaid for Low-Income Seniors

For many older adults and individuals with disabilities, managing healthcare costs can be a significant financial burden. Medicare Savings Programs (MSPs) and state Medicaid programs offer crucial assistance, but navigating the terminology can be confusing. Two of the most commonly misunderstood categories are QMB and QMB+. While both provide vital support, the scope of coverage is quite different and depends on your eligibility for full Medicaid benefits.

What is QMB (Qualified Medicare Beneficiary)?

QMB is a Medicare Savings Program administered by each state’s Medicaid agency. {Link: Medicaid.gov https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/cost-sharing-chart.pdf}.

What is QMB+ (Qualified Medicare Beneficiary Plus)?

QMB+, often referred to as a "full dual-eligible," is for individuals who meet all the criteria for the QMB program and also qualify for full Medicaid benefits in their state. This provides a much more comprehensive level of coverage.

With QMB+, you receive all the benefits of the standard QMB program, including coverage of Medicare premiums and cost-sharing. Additionally, the 'plus' signifies that you also get all the benefits available to full Medicaid recipients in your state. Full Medicaid can cover services that Medicare does not, such as:

• Routine dental care
• Vision and eye exams
• Hearing aids
• Certain long-term care services
• Non-emergency medical transportation

QMB+ acts as a complete secondary insurance that fills the gaps left by Medicare.

Key Differences: QMB vs. QMB+

To clarify the distinction, here is a comparison of the key features of QMB and QMB+.

Feature	QMB (QMB Only)	QMB+ (Full Dual-Eligible)
Primary Function	A Medicare Savings Program (MSP) that acts as partial Medicaid.	A designation for dual-eligibility, meaning you qualify for both QMB and full Medicaid.
Scope of Coverage	Pays for Medicare Parts A and B premiums, deductibles, coinsurance, and copayments only.	Covers all QMB benefits PLUS a wider range of services typically covered by full state Medicaid programs.
Medicaid Eligibility	Does not qualify for full Medicaid benefits.	Qualifies for full Medicaid benefits based on state criteria.
Extra Help (LIS)	Automatically qualifies for the Low Income Subsidy (LIS) to help with Medicare Part D prescription drug costs.	Automatically qualifies for the Low Income Subsidy (LIS).
Dental, Vision, etc.	Does not cover services that are not typically covered by Medicare, like routine dental or vision.	Covers services not typically covered by Medicare, including dental, vision, and hearing.

How to Determine Your Eligibility and Apply

If you are a Medicare beneficiary with a low income, it is essential to determine which program you might qualify for. Eligibility for both QMB and QMB+ is based on your income and resource levels relative to the Federal Poverty Level (FPL).

1. Check the financial limits: Your state's Medicaid website or the official Medicare site will list the current income and resource limits for the QMB program.
2. Contact your state Medicaid office: The application for both QMB and full Medicaid is handled by your state's Medicaid agency.
3. Apply proactively: Even if you think your income is slightly above the threshold, it is still worth applying due to various income and asset disregards.
4. Enrollment and Renewal: If approved, your state will manage enrollment, and you will need to renew eligibility annually.

Conclusion: A Crucial Distinction for Comprehensive Coverage

Understanding what's the difference between QMB and QMB+ is a critical first step toward securing the healthcare coverage you need. While QMB offers substantial relief from Medicare's out-of-pocket costs, QMB+ provides a far more comprehensive safety net by adding full Medicaid benefits. For more information on Medicare Savings Programs, you can visit the official Medicare.gov website.

Frequently Asked Questions

What is a Qualified Medicare Beneficiary (QMB) program?

The Qualified Medicare Beneficiary (QMB) program is a Medicare Savings Program that helps low-income individuals on Medicare pay for their Part A and Part B premiums, deductibles, coinsurance, and copayments.

Who is considered QMB+?

QMB+ is for someone who meets QMB requirements and also qualifies for full Medicaid benefits in their state. They receive both QMB coverage and the broader services of Medicaid.

Does QMB cover dental and vision services?

No, QMB on its own does not cover services not typically covered by Original Medicare, like routine dental or vision. These are generally only covered if you qualify for QMB+ and have full Medicaid benefits.

Can I be billed for a Medicare-covered service if I am in the QMB program?

No. Federal law protects QMB enrollees from being billed for Medicare cost-sharing (premiums, deductibles, coinsurance, and copayments) for Medicare-covered services.

How do I apply for QMB and QMB+?

Apply through your state's Medicaid office, not through Medicare. Your state will assess your income and resources to determine eligibility.

Is QMB eligibility based on federal or state poverty levels?

Eligibility is based on your income and resources relative to the Federal Poverty Level (FPL), but state Medicaid agencies administer the program and may have slightly different guidelines.

What happens if I get a bill that should have been covered by QMB?

Inform the provider that you are a QMB enrollee and not liable for cost-sharing. If the issue persists, contact Medicare or your State Health Insurance Assistance Program (SHIP).

Does QMB enrollment automatically include prescription drug help?

Yes. If approved for QMB, you automatically qualify for the Low Income Subsidy (LIS), or 'Extra Help,' for Medicare Part D prescription drug costs.