The Issue
Medicare Part A covers hospital care, as well as some types of long-term care that older adults may need. Most individuals with some work history are entitled to Medicare Part A without having to pay any premium, because they paid into it through federal tax deductions from their employment earnings over the course of their work life. Some older adults, however, either never paid into Medicare A or did not have enough hours in a qualifying job to qualify. As a result, they are uninsured for Part A.
Once they turn 65, however, these uninsured individuals can buy Medicare Part A by paying a monthly premium for it, just as for Part B. While this may be prohibitively expensive, some low-income older adults may qualify for a program called Qualified Medicare Beneficiary program (QMB) which will pay the Medicare Part A premium for them (plus the Part B premium and all deductibles and co-insurances).
Applying for the QMB program, however, can involve running a gauntlet between the state Medicaid office and the Social Security Administration (SSA). In many cases, people must first apply for conditional Part A at SSA and then apply for QMB at their state Medicaid office. In some states, the SSA application can only be filed during a three-month window at the beginning of every year.
Advocates have reported that SSA staff often have given wrong information about this process or do not understand proper procedures for handling a conditional Part A application. These inconsistencies have confused and frustrated advocates and beneficiaries alike.
What is QMB?
Under the QMB benefit, state Medicaid programs pay the over $500/month Part A premium in addition to the Part B premium. Since QMB also pays for Medicare related cost sharing including the deductibles and copays under both Medicare A and B, health care providers cannot bill QMB enrollees for any services covered by Medicare. The QMB program is generally available to people with incomes at or below 100% of the Federal Poverty Level with limited assets, but qualification requirements can be more generous in some states.
The Fix
The SSA Program Operations Manual System (POMS) HI 00801.140 gives staff precise instructions on how to ensure that a conditional Part A application is handled correctly. The POMS provision gives specific wording to add to an application to ensure that it is treated as “conditional.” Note that the POMS revisions do not make any substantive changes to the processing requirements, but they spell them out in much more detail.
Differences Among States
The instructions explain that individuals in most states (Part A “buy-in” states) can apply for conditional Part A at any time in the year. With proof of conditional application, they can then immediately apply for the QMB program with their state Medicaid program.
However, in 13 states (Part A “Group Payer” states) SSA can only accept conditional Part A applications during the General Enrollment Period, which extends from January 1 through March 31, or during the individual’s initial enrollment period or special enrollment period. Starting in 2023, for individuals applying during the General Enrollment Period, enrollment in Part A (and thus eligibility to apply for QMB) will be effective the month after the application for Part A is filed. The Group Payer states are Alabama, Arizona, Colorado, Illinois, Kansas, Kentucky, Missouri, Nebraska, New Jersey, New Mexico, South Carolina, Utah, and Virginia. As of January 1, 2025, California became a Part A buy-in state allowing low-income Californians eligible for QMB to apply for conditional Part A at any time in the year. Building on the lessons learned in California, a Justice in Aging issue brief provides advocates in group payer states with strategies to transition to a Part A buy-in state.
Tips for Advocates
In Group Payer states (AL, AZ, CO, IL, KS, KY, MO, NE, NJ, NM, SC, UT, and VA):
- Prospective QMB applicants without premium-free Part A may only apply at SSA for conditional Part A enrollment between January 1 and March 31 or during other enrollment periods (e.g. initial enrollment period; special enrollment periods). SSA will not accept applications at other times.
- Even if the individual already is enrolled in Part B, they must conditionally enroll in Part A. Carefully explain to your client the two steps they must take to conditionally apply for QMB.
- After having applied at SSA, the client should apply for QMB at the state’s Medicaid office and should do so promptly (i.e., within the same month that they applied for Medicare Part A).
In all other states (Part A Buy-In States):
- If someone is not enrolled in Part B, and does not have premium-free Part A, they must apply for conditional Part A enrollment at their SSA office.
- They can apply at any time of the year. After filing for conditional Part A, they should then apply for QMB at their state Medicaid office.
- If someone is already enrolled in Part B, they do not have to apply for conditional Part A enrollment. They can apply for QMB at their state Medicaid office directly. They can do this at any time in the year.
In all states:
- Use the magic words. When you send a client to the SSA office, tell the client to say that they want to apply for conditional Part A enrollment under HI 00801.140 in order to apply for the state QMB program. Consider giving your client a copy of the POMS to bring to the SSA office.
- Tell your client to ask for a screenshot of the application with confirmation of filing and to bring it to the Medicaid office when applying for QMB.
- Once QMB enrollment is completed, encourage your client to talk with a SHIP counselor to help the client understand their Medicare coverage and enrollment choices. SHIP counselors can, for example, help the client understand the differences between a Medicare Advantage plan and Original Medicare. QMB also entitles enrollees to receive the Low-Income Subsidy or Extra Help program which provides a premium-free, zero-deductible, low-copay Part D drug prescription plan. Counselors can also help clients choose Medicare Part D prescription drug coverage that best meets their needs.
- The earliest that QMB status will begin is the first day of the month after the month in which the state Medicaid application was approved. Explain to your client that it may take a few more months for SSA to actually stop taking the premium out of the client’s monthly Social Security benefit. Clients should monitor their benefit payments—if the deductions for Medicare premiums have not stopped within three months of the award of QMB, they should return to their local state Medicaid office where they filed their QMB application to report this problem.