Revision 09-4; Effective December 1, 2009

Acceptable verification for Medicare enrollment for Part A includes:

• Wire Third Party Query (WTPY);
• State On line Query (SOLQ);
• Medicare card;
• an enrollment letter from the Social Security Administration documenting enrollment in Part A; and
• presumptive eligibility (persons age 65 years and older receiving RSDI or Railroad Retirement can be presumed enrolled in Medicare Part A, unless their Social Security claim number suffix ends in J3, J4, K3, K4, K7, K8, KB, KC, KF, KG, KL and KM).

Revision 09-4; Effective December 1, 2009

Texas is a "buy-in" state. There is no restricted enrollment period. HHSC can automatically "add on" a person's Medicare Part A entitlement and pay the Medicare Part A premium at any time during the year. In other words, if the applicant has Part A, is enrolling for Part A or is entitled to Part A, the applicant may be certified for QMB.

Q-2210 Upon Certification of QMB

Revision 09-4; Effective December 1, 2009

• If the person has Part B only (or is enrolling for Part B), the state will add on the person's Part A entitlement.
• If the person has Part A only, the state will automatically add on the Part B entitlement.
• The state will not pay any expenses until Part A and B premiums begin.

The only "conditional" left is if a person does not have Part A or B. However, we do not have to wait to put the person on QMB.

Revision 10-4; Effective December 1, 2010

Although most people who are eligible for Medicare Part A receive free Part A coverage, some are required to pay a monthly premium.

A person is entitled to Medicare Part A if the person meets one of the following conditions:

• The person does not have to pay Medicare Part A, and is receiving Medicare Part A services as of the QMB determination.
  
  Example: Mrs. Smith applies for QMB benefits Aug. 15. She has a Medicare card with a Part A begin date of June 1. Since Medicare will pay for Part A services as of June 1, she is entitled to Part A at the time of the QMB determination.
• The person is a Medicaid recipient or QMB or Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Disabled and Working Persons (QDWI) applicant and has never been enrolled in the federal Medicare system. In this case the person must apply at the local Social Security Administration (SSA) office for Part A Medicare eligibility. The person will receive a receipt that entitles the person to enrollment in Part A on the condition that the person is found eligible for QMB or SLMB. The receipt from SSA will have a Part A begin date on it. QMB or SLMB or QDWI eligibility cannot begin before the Part A begin date.
  
  Example: Mrs. Brown was never enrolled in the federal Medicare system. She applies for QMB. The eligibility specialist takes her application and pends it. Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare. She contacts SSA and is conditionally determined eligible for Part A. Her QMB application is completed.

The eligibility specialist may receive a referral from SSA. An application will be sent to a person with conditional Part A enrollment if there is not a current pending QMB application already on file.

The person's Wire Third Party Query (WTPY) verifies conditional Part A enrollment when the Social Security claim number ends in M and:

• the Part A payment code status is Z99 and there is an entitlement date to Medicare Part B; or
• there is no entitlement date for Part A and there is an entitlement date to Part B.

Proof of conditional enrollment in Part A fulfills the QMB eligibility requirement of entitlement to Medicare Part A.

Note: Do not presume that a person enrolled in Medicare Part B is also enrolled in Medicare Part A. Persons drawing early retirement (RSDI) (usually at the age of 62) are not eligible for Medicare Part A or B. Persons determined disabled by SSA and under age 65 are not eligible to enroll in Medicare until they have been disabled for 24 consecutive months or reach their 65th birthday, whichever comes first.

Revision 12-2; Effective June 1, 2012

QMB recipients do not receive regular Medicaid benefits. HHSC sends these persons a Your Texas Benefits Medicaid Card that reflects QMB status.

Medicaid pays out-of-pocket Medicare cost-sharing expenses for QMB recipients. Medicaid does not limit deductible or coinsurance payments to services covered by the State Plan.

Revision 26-2; Effective June 1, 2026

Monthly income cannot exceed 100% of the federal poverty level (FPL).

Use the couple income range when both spouses are applying for the same program.

Monthly Income Limits for the QMB Program

*The deeming allowance is the couple limit minus the individual limit.

Note: These amounts do not include the $20 disregard.

Related Policy

MSP Resource Limits, Q-1300
Budget Reference Chart, Appendix XXXI

Revision 20-3; Effective September 1, 2020

Revision 12-4; Effective December 1, 2012

QMB eligibility begins on the first day of the month following the month the person is determined eligible for QMB benefits. The disposition date in the system of record is the date the eligibility decision is completed. For example, if the MC – QMB is signed and disposed on Jan. 2, QMB eligibility would begin on Feb.1.

There is no QMB coverage in the three months prior to the QMB application date or coverage for months up to the QMB effective date. The only exception is if the individual is eligible for continuous QMB. See details listed in Section Q-2800, Ensuring Continuous QMB.

Q-2710 Prior Coverage Under SLMB/QI-1

Revision 12-2; Effective June 1, 2012

Institutional living arrangement (including persons residing in state supported living centers and ICF/ID facilities, and persons age 65 and over residing in institutions for mental diseases (IMDs)).

Situation 1

A person does not reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Situation 2

A person does reside in the institution during the entire three prior months.

An applicant who is QMB eligible ongoing may be eligible for SLMB in the three prior months when the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income, such as additional income was received in the prior months.

Note: Deeming and support and maintenance is not applicable to institutional or Home and Community-Based Services waiver programs but is applicable to QMB, SLMB, and QI-1.

Living in the community, including persons applying for Community Attendant Services (CAS) and persons residing at home and applying for Home and Community-Based Services waiver programs:

Situation

An applicant who is QMB eligible ongoing may be eligible for SLMB or QI-1 in the three prior months when the individual's income exceeds the QMB limits in the prior months. This situation occurs when there has been a decrease in countable ongoing income or when deemed income or support and maintenance was countable in the prior months.

Reminder

QI-1 persons cannot be eligible for regular Medicaid and QI-1 benefits at the same time. Always give applicants the opportunity to choose which benefit they prefer to receive and document the person's verbal or written choice of preferred benefit, including a choice between QI-1 and CAS benefits. For QI-1, the three months prior period cannot extend back into the previous calendar year unless the application was filed in that calendar year. The application file date and prior coverage months must be in the same calendar year.

Example 1: February is the application month, which makes January the only possible prior coverage month.

Example 2: December is the application month; thus, the three months prior would be September, October and November. Applicant could be potentially eligible for the three months prior, the application month of December and for January and ongoing.

Note: Refer to Section Q-3400, SLMB Medical Effective Date, for policy regarding the prior months.

Revision 24-3; Effective Sept. 1, 2024

When a person loses eligibility for SSI and applies for Medicaid, verify if they were receiving QMB benefits at the time of SSI denial by reviewing:

• Medicaid History in TIERS;
• Eligibility History in TIERS;
• State On-Line Query (SOLQ) response; or
• Wire Third-Party Query (WTPY) response.

If the person was receiving SSI and QMB and is eligible for ongoing QMB after the SSI termination, the effective begin date for QMB benefits is the day immediately following the SSI termination date. This ensures continuous QMB coverage.

Examples:

• The last day of SSI and QMB coverage is Jan. 31st. The person is eligible ongoing for ME-Pickle and MC-QMB. The effective begin date for ongoing MC-QMB is Feb. 1st.
• The last day of SSI and QMB coverage is Jan. 31st. The person is eligible for MC-QMB. The effective begin date for ongoing MC-QMB is Feb. 1st.

Though there is no limit to how far back continuous QMB coverage may be granted, system limitations will not allow Medicare Part B buy-in reimbursement to start any earlier than two full fiscal years before the date the buy-in process is successfully completed.  Note: The fiscal year begins in September for this purpose.

Examples:

• SSI with QMB was terminated Dec. 31, 2017. The person applies for QMB on April 7, 2020. Continuous QMB is approved on May 15, 2020. The continuous QMB effective date is Jan. 1, 2018, but the buy-in process is not completed until July 15, 2020.
  Buy-in is effective January 2018. The current fiscal year began September 2019 and the prior two fiscal year period began September 2017.
• SSI with QMB was denied Dec. 31, 2017. The person applies for QMB on Aug. 15, 2020 and is approved for continuous QMB on Sept. 11, 2020. The QMB effective date is Jan. 1, 2018, but buy-in process is not completed until Nov. 15, 2020.
  Buy-in is effective September 2018. The current fiscal year began September 2020 and the prior two fiscal year period began September 2018.
   

Buy-in is effective September 2018. The current fiscal year began September 2020 and the prior two fiscal year period began September 2018.

What is not considered Continuous QMB:

• QMB recipient was denied in error because income was incorrectly counted in the budget. The case must be corrected to add the missing coverage the recipient is entitled to receive.
• QMB recipient was correctly denied for exceeding the income or resource limits. This is a valid denial and a break in coverage. At reapplication, continuous QMB does not apply. The QMB effective date is the first of the month after disposition.
• QMB recipient was denied because the redetermination packet was lost or misrouted in the task list manager queue. The case must be corrected to add the missing coverage the recipient is entitled to receive.
• QMB recipient was denied at redetermination for failure to return a renewal form. This is a valid denial. At reapplication, the QMB effective date is the first of the month after disposition.

Continuous QMB for Medicare Part B-ID Recipients

Ensure continuous QMB coverage if the person was receiving regular QMB coverage one month and is eligible for Part B-ID QMB the following month.

Revision 13-4; Effective December 1, 2013

Persons receiving Medicaid benefits under SSI also may qualify for QMB. QMB status is automatically added to the Medicaid coverage when the person also receives Medicare Part A. QMB eligibility is effective the month after the tape match from SSA is received.

Example: The tape match with SSA is received in September 20XX indicating the SSI recipient is Medicare Part A eligible August 20XX. QMB eligibility will begin in October 20XX.

In situations where the SSI recipient should have QMB coverage but does not, the eligibility specialist emails all inquiries or necessary updates to CCC_Data_Integrity_Program@hhsc.state.tx.us. The turnaround time is 24 to 36 hours, depending on the number of inquiries received. Send the following information with your request:

• Individual's number
• Individual's name
• Case number and EDG number
• Medical coverage requested, including certification period
• Add or delete coverage requested
• Any special instructions that have to do with Medicaid coverage