Once you’ve reached the age for Medicare eligibility, even if you’re still participating in triathlons and eating the cleanest diet, the human body is more prone to complications. Keeping up with myriad preventive screenings and a weakened immune system due to natural wear and tear gets expensive, especially if you’re already making less money than your medical bills demand. Medicare also covers the disabled, who can certainly need additional help when attempting to care for their condition. This is where dual eligibility comes in. An assistance program in each state to help individuals over age 65 and with disabilities afford the proper care and coverage.
Low-income individuals enrolled in Medicare can receive financial assistance with their healthcare and coverage costs through the Medicaid program in their state. Depending on your income and assets, you may qualify for help paying your premiums and/or cost sharing, or be able to receive full Medicaid benefits as a dual eligible member. If your income changes, your eligibility may change, as well, as different incomes result in varying benefits.
Perhaps you are already familiar with the terms Qualified Medicare Beneficiary or Specified Low-Income Medicare Beneficiary, but are unsure exactly the criteria needed to belong in one of these categories. In many states, dual eligibility is broken down further into QMB+ and SLMB+, the “plus” indicating eligibility for full Medicaid coverage. Refer to the definitions below as well as the current federal poverty guidelines to determine your potential eligibility for assistance with expenses related to your health insurance plan and medical care.
Levels of Dual Eligibility
QMB+: Up to 80% FPL
A Qualified Medicare Beneficiary (QMB+) earns less than or equal to 80 percent of poverty (80% FPL), and is considered a zero cost share dual eligible member, as they do not have to pay Part A (hospital) or Part B (medical) cost sharing. Such individuals can receive full Medicaid benefits and no cost sharing (coinsurance, deductibles and copayments, not premiums) for Part A and B covered services.
QMB: 80-100% FPL
A Qualified Medicare Beneficiary (QMB) has income between 80 and 100 percent of the poverty line (80-100% FPL) and is not responsible for paying Medicare Part A or Part B cost sharing. Regular QMBs are not eligible for full Medicaid coverage, but Medicaid pays for covered hospital and medical care under Medicare.
SLMB+: 100-120% FPL
A Specified Low-Income Medicare Beneficiary (SLMB+) earns between 100 and 120 percent of federal poverty (100-120% FPL) and is eligible for full Medicaid coverage as well as zero cost sharing for Medicare Part A and Part B. In order to qualify for Medicaid benefits, they must not be responsible for Part A and Part B cost sharing. Essentially, many covered services are available for free to these members.
SLMB: 100-120% FPL
A Specified Low-Income Medicare Beneficiary (SLMB) also has income between 100 and 120 percent of poverty (100-120% FPL), but is considered partially responsible for Part A and Part B cost sharing. Therefore, they are not eligible for full Medicaid.
QI: 120-135% FPL
A Qualifying Individual (QI) earns between 120 and 135 percent of federal poverty level (120-135% FPL) and is counted as a partial dual eligible member because they still have to pay cost sharing for Medicare Part A and Part B. Their income does qualify them for some assistance, however.
QDWI: 135-200% FPL
If you’re working and disabled, you don’t have to lose your benefits and you can receive assistance. Qualified Disabled Working Individuals have income between 135 and 300 percent of the poverty guideline (135-200% FPL) and are considered partially dual eligible, as they pay for Part A and Part B cost sharing. Full Medicaid is not available to these Medicare members.
Full Benefit Dual Eligibles have income that allows them to receive full Medicaid benefits, as they qualify for zero cost sharing. This applies to QMB+ and SLMB+ members.
Zero Cost Share Dual Eligible Member
These Medicare-Medicaid individuals are eligible to receive 100 percent coverage for their Part A and Part B cost sharing. This includes QMB+, QMB, SLMB+ and FBDE beneficiaries.
Medicare Savings Program
If you are deemed eligible for one of these groups, you may be able to receive assistance with certain Medicare premiums and cost sharing, and have access to full Medicaid benefits. The Medicare Savings Program (MSP) is available through your state health department and provides assistance with various medical costs to dual eligibles, including policy-related expenses for hospital and medical portions of Medicare for some members. MSP contains various categories depending on income level, assets, and “medically needy” status. The Social Security Administration (SSA) determines who qualifies and will notify dual eligible members in an award letter, which will indicate whether the recipient is a QMB+, SLMB, QI, etc.
The benefits for the varying groups of dual eligible members are listed below, including whether premiums, cost sharing, and full Medicaid assistance are offered. Those who qualify as QMB, QMB+, SLMB+ and FBDE are considered zero cost share dual eligible members, as they aren’t required to pay for Medicare Part A or B.