Medicaid for the Elderly and People with Disabilities Handbook

Q-1000, Medicare Savings Programs Overview

Revision 25-1; Effective March 1, 2025

The Medicare Savings Programs (MSPs) help Medicare beneficiaries with limited income and resources pay for all or some of their out-of-pocket Medicare expenses. These expenses include premiums, deductibles and coinsurance.

There are four types of MSPs:

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled and Working Individual (QDWI) Program

The income limits for the MSPs are based on the federal poverty level (FPL), which is adjusted annually.

The resource limits for the MSPs, except QDWI, are updated annually based on the Consumer Price Index (CPI). The QDWI resource limits are based on the current SSI resource limits. All regular Medicaid for the Elderly and People with Disabilities (MEPD) policies for resources, income and non-financial eligibility apply to this program, except those specifically identified in this chapter.

Transfer of assets, spousal impoverishment and co-payment policy and procedures do not apply to MSPs.

A person is not eligible for MSP coverage if they:

  • are in the custody of penal authorities; or
  • are over 20 but under 65 years and live in an institution for mental diseases (IMD).

Note: Children under 19 who are certified for MSP will receive 12 months of continuous eligibility, with limited exceptions. Refer to continuous Medicaid coverage policy for exceptions.

Related Policy

Medicare Savings Program Information, Appendix IX
Medicare Savings Programs, A-8000
Continuous Medicaid Coverage, B-6600

 

Q-1100, Reserved for Future Use

Revision 24-4; Effective Dec. 1, 2024

Q-1200, Medicare Improvement for Patients and Providers Act of 2008

Revision 22-3; Effective September 1, 2022

MIPPA added requirements for processing MSP applications for people applying through the Social Security Administration (SSA) for the Low Income Subsidy (LIS) program, also referred to as the Extra Help program. LIS provides prescription assistance for Medicare beneficiaries enrolled in Medicare Part D who have limited income and resources. The MSP programs included in MIPPA are:

  • Qualified Medicare Beneficiary (QMB) Program;
  • Specified Low-Income Medicare Beneficiary (SLMB) Program; and
  • Qualified Individual (QI) Program.

The Qualified Disabled and Working Individual (QDWI) Program is not part of MIPPA.

Texas receives a list of people who applied for LIS from SSA. The list includes whether the people were approved or denied. The date the Texas Health and Human Services Commission (HHSC) receives the list is the application date for MSP and starts the 45-day clock for timely processing of the applications for each person on the list. The date the application was made with SSA is a protected file date for MSP eligibility. Form H1200-EZ, Application for Assistance — Aged and Disabled is sent to each person on the list. HHSC sends denied LIS applicants a denial notice with the right to appeal if they are denied because they:

  • live outside the United States;
  • have excess resources; or
  • have excess income (couples will not auto deny).

Additionally, TIERS will deny anyone identified as living outside of Texas.

Q-1300, MSP Resource Limits

Revision 25-1; Effective March 1, 2025

QMB, SLMB and QI Resource Limits

The resource limits for the following Medicare Savings Programs (MSP) are based on the annual consumer price index (CPI). They are updated in January of each year:

  • Qualified Medicare Beneficiary (QMB);
  • Specified Low-Income Medicare Beneficiary (SLMB); and
  • Qualified Individual (QI).

Use the following resource limits when determining eligibility for these programs.

Date RangeIndividualCouple
Jan. 1, 2025 to Present$9,660$14,470
Jan. 1, 2024 to Dec. 31, 2024$9,430$14,130
Jan. 1, 2023 to Dec. 31, 2023$9,090$13,630
Jan. 1, 2022 to Dec. 31, 2022$8,400$12,600
Jan. 1, 2021 to Dec. 31, 2021$7,970$11,960
Jan. 1, 2020 to Dec. 31, 2020$7,860$11,800
Jan. 1, 2019 to Dec. 31, 2019$7,730$11,600
Jan. 1, 2018 to Dec. 31, 2018$7,560$11,340
Jan. 1, 2017 to Dec. 31, 2017$7,390$11,090
Jan. 1, 2016 to Dec. 31, 2016$7,280$10,930
Jan. 1, 2015 to Dec. 31, 2015$7,280$10,930
Jan. 1, 2014 to Dec. 31, 2014$7,160$10,750
Jan. 1, 2013 to Dec. 31, 2013$7,080$10,620
Jan. 1, 2012 to Dec. 31, 2012$6,940$10,410
Jan. 1, 2011 to Dec. 31, 2011$6,680$10,020
Jan. 1, 2010 to Dec. 31, 2010$6,600$9,910
Jan. 1, 1989 to Dec. 31, 2009$4,000$6,000

QDWI Resource Limits

The resource limits for Qualified Disabled and Working Individuals (QDWI) are twice the resource limits for the SSI program.

Use the following resource limits when determining eligibility for the QDWI program:

  • $4,000 for an individual; and
  • $6,000 for a couple.

Related Policy

Resource Limits, F-1300
Medicare Savings Program Information, Appendix IX
Budget Reference Chart, Appendix XXXI

Q-1400, MSPs and Cost-of-Living Adjustments

Revision 20-3; Effective September 1, 2020

The income limits for QMB, SLMB and QI are based on the federal poverty level (FPL), which is adjusted annually. The Social Security cost-of-living adjustment (COLA) is excluded through the month in which the annual revision of the FPL is published. To determine eligibility for applications and redeterminations, use the pre-COLA benefit amount during those months.

For example, if the FPL is published in February, exclude the RSDI COLA for the months of January and February.

Reminder: The COLA exclusion does not apply when determining eligibility for the QDWI program.

Related Policy

Deeming Income, E-7000
QDWI Cost-of-Living Adjustment, Q-6300

Q-1500, MSPs and Medicare Part B-ID

Revision 25-1; Effective March 1, 2025

A person diagnosed with end-stage renal disease (ESRD) may be entitled to Medicare benefits. If the person receives a kidney transplant, Medicare entitlement ends after 36 months, unless the person is otherwise entitled to Medicare based on age or disability.

Medicare beneficiaries who lose Medicare eligibility after a kidney transplant may be eligible for the limited Medicare Part B immunosuppressive drug (Medicare Part B-ID) benefit. Medicare Part B-ID beneficiaries are not entitled to Medicare Part A, cannot be eligible for Medicare on another basis, and must not have any other comprehensive health care coverage that covers immunosuppressive drugs, such as Medicaid or the Children’s Health Insurance Program (CHIP). A Medicare Part B-ID beneficiary may be eligible for Community Attendant Services (CAS) or the Healthy Texas Women (HTW) program because these types of assistance do not cover immunosuppressive drugs.

The Medicare Part B-ID benefit only covers immunosuppressive drugs. Medicare does not cover any other items or services, including hospital stays, physician services, supplies or medications.

Eligible Part B-ID beneficiaries receive a new Medicare card that shows Medicare coverage for immunosuppressive drugs only.

Part B-ID beneficiaries with limited income and resources may be eligible for a Medicare Savings Program (MSP) even though they are not entitled to Medicare Part A. If the person meets all other eligibility requirements, the MSP will cover all or some of the person’s Medicare premiums, deductibles or coinsurance associated with the Part B-ID benefit.

Identification

Identify Medicare Part B-ID individuals by accessing State Online Query (SOLQ) or viewing the person’s Medicare card. In SOLQ, the Ledger Account File (LAF) code will display Active Title XVIII status only. Medicare Part B will reflect a start date with a premium amount lower than the standard Medicare Part B premium. The 2025 Part B-ID premium is $110.40. In addition, Medicare Part A will reflect a stop date with the option code None-No longer under renal disease provision.

Regular MSP and Part B-ID MSP in TIERS

Regular MSPs are Qualified Medicaid Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI-1) benefits based on entitlement for Medicare Part A. Part B-ID MSPs are QMB, SLMB or QI-1 benefits based on entitlement for Medicare Part B-ID. Part B-ID MSPs help with Medicare Part B-ID premiums, deductibles and co-insurance costs associated with immunosuppressive drugs only. A person approved for Part B-ID QMB does not receive regular QMB benefits. The Medicaid card for Part B-ID QMB recipients shows Part B-ID only in the upper righthand corner.

A regular MSP recipient who loses Medicare Part A entitlement based on ESRD and transfer to Part B-ID MSP receives a new Eligibility Determination Group (EDG) number in TIERS. The new EDG keeps the same review due date, packet sent date and packet received date as the old EDG, if the person is certified for the same type of assistance (TOA).

Q-2000, Qualified Medicare Beneficiaries

Revision 25-1; Effective March 1, 2025

A person diagnosed with end-stage renal disease (ESRD) may be entitled to Medicare benefits. If the person receives a kidney transplant, Medicare entitlement ends after 36 months, unless the person is otherwise entitled to Medicare based on age or disability.

Medicare beneficiaries who lose Medicare eligibility after a kidney transplant may be eligible for the limited Medicare Part B immunosuppressive drug (Medicare Part B-ID) benefit. Medicare Part B-ID beneficiaries are not entitled to Medicare Part A, cannot be eligible for Medicare on another basis, and must not have any other comprehensive health care coverage that covers immunosuppressive drugs, such as Medicaid or the Children’s Health Insurance Program (CHIP). A Medicare Part B-ID beneficiary may be eligible for Community Attendant Services (CAS) or the Healthy Texas Women (HTW) program because these types of assistance do not cover immunosuppressive drugs.

The Medicare Part B-ID benefit only covers immunosuppressive drugs. Medicare does not cover any other items or services, including hospital stays, physician services, supplies or medications.

Eligible Part B-ID beneficiaries receive a new Medicare card that shows Medicare coverage for immunosuppressive drugs only.

Part B-ID beneficiaries with limited income and resources may be eligible for a Medicare Savings Program (MSP) even though they are not entitled to Medicare Part A. If the person meets all other eligibility requirements, the MSP will cover all or some of the person’s Medicare premiums, deductibles or coinsurance associated with the Part B-ID benefit.

Identification

Identify Medicare Part B-ID individuals by accessing State Online Query (SOLQ) or viewing the person’s Medicare card. In SOLQ, the Ledger Account File (LAF) code will display Active Title XVIII status only. Medicare Part B will reflect a start date with a premium amount lower than the standard Medicare Part B premium. The 2025 Part B-ID premium is $110.40. In addition, Medicare Part A will reflect a stop date with the option code None-No longer under renal disease provision.

Regular MSP and Part B-ID MSP in TIERS

Regular MSPs are Qualified Medicaid Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI-1) benefits based on entitlement for Medicare Part A. Part B-ID MSPs are QMB, SLMB or QI-1 benefits based on entitlement for Medicare Part B-ID. Part B-ID MSPs help with Medicare Part B-ID premiums, deductibles and co-insurance costs associated with immunosuppressive drugs only. A person approved for Part B-ID QMB does not receive regular QMB benefits. The Medicaid card for Part B-ID QMB recipients shows Part B-ID only in the upper righthand corner.

A regular MSP recipient who loses Medicare Part A entitlement based on ESRD and transfer to Part B-ID MSP receives a new Eligibility Determination Group (EDG) number in TIERS. The new EDG keeps the same review due date, packet sent date and packet received date as the old EDG, if the person is certified for the same type of assistance (TOA).

Q-2100, Verification and Documentation for QMB

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).

Q-2200, Conditional QMB

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.

Q-2300, Social Security Administration QMB Referral Procedures

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.

Q-2400, QMB Benefits

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.

Q-2500, QMB Income Limits

Revision 24-2; Effective June 1, 2024

Monthly income cannot exceed 100 percent FPL.

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

Monthly Income Limits for the QMB Program

Time PeriodIndividualCoupleDeeming*
March 1, 2024 to Present$1,255$1,704$449
March 1, 2023 to Feb. 29, 2024$1,215$1,643$428
March 1, 2022 to Feb. 28, 2023$1,133$1,526$393
March 1, 2021 to Feb. 28, 2022$1074$1452$378
March 1, 2020 to Feb. 28, 2021$1064$1437$373
March 1, 2019 to Feb. 29, 2020$1041$1410$369
March 1, 2018 to Feb. 28, 2019$1012$1372$360
March 1, 2017 to Feb. 28, 2018$1005$1354$349
March 1, 2016 to Feb. 28, 2017$990$1,335$345
March 1, 2015 to Feb. 29, 2016$981$1,328$347
March 1, 2014 to Feb. 28, 2015$973$1,311$338
March 1, 2013 to Feb. 28, 2014$958$1,293$335
March 1, 2012 to Feb. 28, 2013$931$1,261$330
March 1, 2011 to Feb. 29, 2012$908$1,226$318
March 1, 2009 to Feb. 28, 2011$903$1,215$312

*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

Q-2700, QMB Medical Effective Date

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.

Q-2800, Ensuring Continuous QMB

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:

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.

Q-2900, QMB Eligibility and Supplemental Security Income

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

Q-3000, Specified Low-Income Medicare Beneficiaries

Revision 24-3; Effective Sept. 1, 2024

The Specified Low-Income Medicare Beneficiary (SLMB) program pays only the Medicare premiums for people who meet all eligibility requirements.

SLMB has the same eligibility criteria as QMB except the person’s countable income must be more than 100% but less than 120% of the federal poverty level (FPL).

A person can be dually eligible for both SLMB and any full Medicaid program other than Pickle and Disabled Adult Child (DAC).

Note: ME-Pickle and ME-Disabled Adult Child recipients cannot be dually eligible for SLMB because payment of the Medicare Part B premium is already included in the Medicaid benefit.

The following may be certified for SLMB if all eligibility criteria are met:

Related Policy

Medicare Savings Program Information, Appendix IX
Specified Low-Income Medicare Beneficiaries (SLMB), A-8200
Medicare Savings Program Overview, Q-1000
MSP Resource Limits, Q-1300
MSPs and Medicare Part B-ID, Q-1500
Qualified Medicare Beneficiaries, Q-2000
Medicare Savings Programs and Dual Eligibility, Q-4000

Q-3100, SLMB Benefits

Revision 09-4; Effective December 1, 2009

For SLMB-eligible persons, Medicaid pays only Medicare Part B premiums. However, enrollment in Medicare Part B is not an eligibility criterion.

Q-3200, SLMB Income Limits

Revision 24-2; Effective June 1, 2024

Monthly income must be more than 100 percent FPL and less than 120 percent FPL.

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

Monthly Income Limits for the SLMB Program

Time PeriodIndividual LimitCouple LimitDeeming*
March 1, 2024 to Present$1,255.01 to $1,506$1,704.01 to $2,044$538
March 1, 2023 to Feb. 29, 2024$1,215.01 to $1,458$1,643.01 to $1,972$514
March 1, 2022 to Feb. 28, 2023$1,133.01 to $1,359$1,526.01 to $1,831$472
March 1, 2021 to Feb. 28, 2022$1,074.01 to $1,288$1,452.01 to $1,742$454
March 1, 2020 to Feb. 28, 2021$1,064.01 to $1,276$1,437.01 to $1,724$448
March 1, 2019 to Feb. 29, 2020$1,041.01 to $1,249$1410.01 to $1,691$442
March 1, 2018 to Feb. 28, 2019$1,012.01 to $1,214$1,372.01 to $1,646$432
March 1, 2017 to Feb. 28, 2018$1,005.01 to $1,206$1,354.01 to $1,624$418
March 1, 2016 to Feb. 28, 2017$990.01 to $1,188$1,335.01 to $1,602$414
March 1, 2015 to Feb. 29, 2016$981.01 to $1,177$1,328.01 to $1,593$416
March 1, 2014 to Feb. 28, 2015$973.01 to $1,167$1,311.01 to $1,573$406
March 1, 2013 to Feb. 28, 2014$958.01 to $1,149$1,293.01 to $1,551$402
March 1, 2012 to Feb. 28, 2013$931.01 to $1,117$1,261.01 to $1,513$396
March 1, 2011 to Feb. 29, 2012$908.01 to $1,089$1,226.01 to $1,471$382

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

Note: These amounts do not include the $20 disregard. There must be at least a one cent unmet need for SLMB (MC-SLMB) eligibility.

Related Policy

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

Q-3400, SLMB Medical Effective Date

Revision 13-3; Effective September 1, 2013

A person's SLMB eligibility may begin with the month of application. A person with SLMB coverage is eligible for three months prior medical coverage, if all criteria are met.

Do not grant SLMB coverage for QMB applicants whose monthly income is equal to or less than the QMB limit during the three months prior through the QMB eligibility effective date.

SLMB in the three prior months is allowed with ongoing QMB if the individual’s income exceeds the QMB limits in the prior months. This situation occurs when there has been a change in countable ongoing income.

Q-3500, SLMB Eligibility and Other Programs

Revision 12-2; Effective June 1, 2012

When a Specified Low-Income Medicare Beneficiary (MC-SLMB) recipient becomes eligible for Supplementary Security Income (SSI), the MC-SLMB EDG in TIERS is automatically denied since SLMB is not allowed with SSI.

ME – Pickle, ME – SSI Prior, ME – Disabled Adult Child, and ME – A and D – Emergency cannot be dually eligible for SLMB. Even though ME – Pickle and ME – Disabled Adult Child may meet SLMB eligibility requirements, the Medicare Part B premium is already paid

Notes:

  • ME – Early Aged Widow(er) and Disabled Widow(er) cannot be entitled to Medicare; therefore, not eligible for any MSP Program.
  • A person is not eligible for SLMB coverage if the person is:
    • in the custody of penal authorities; or
    • over 20 years of age and under 65 years of age and resides in an institution for mental diseases (IMD).
  • Persons age 65 or older residing in an IMD may be certified for SLMB, if all eligibility criteria are met. Persons of any age residing in state supported living centers may be certified for SLMB, if all eligibility criteria are met. SLMB ongoing and prior coverage is available for ICF/ID and state supported living center residents.
  • SLMB ongoing and prior coverage is allowed with ME – Nursing Facility, which includes individuals on Mason Manor.
  • SLMB ongoing and prior coverage is allowed with ME – Waivers.

Q-4000, Medicare Savings Programs and Dual Eligibility

Q-4100, SLMB Dual Eligibility and Medicare Buy-In

Revision 13-4; Effective December 1, 2013

Programs ME-Pickle, ME-SSI Prior, ME-Temp Manual SSI, ME-SSI, ME-Disabled Adult Child, MC-QMB, and ME-A and D-Emergency cannot be dually eligible for SLMB. Even though ME-Pickle and ME-Disabled Adult Child recipients may meet SLMB eligibility requirements, the Medicare Part B premium is already paid because they are on Medicaid.

Q-4200, Texas Works Medicaid and QMB or SLMB Dual Eligibility

Revision 20-2; Effective June 1, 2020

Persons receiving Medicaid benefits through Texas Works Medical Programs also may qualify for QMB benefits.

These programs include the following:

  • MA – Earnings Transitional (TP 07)
  • MA – Parents and Caretaker Relatives (TP08)
  • MA – Pregnant Women (TP 40)
  • MA – Children Under 1 (TP 43)
  • MA – Newborn Children (TP 45)
  • MA – Children 1-5 (TP 48)
  • MA – Children 6-18 (TP 44)
  • MA – Former Foster Care Children (FFCC) (TA 82)

The above programs cannot be dually eligible for SLMB. Even though these programs may meet SLMB eligibility requirements, the Medicare Part B premium is already paid.

A person receiving (TP-56) MA-Medically Needed Spend Down can be eligible for MC-SLMB.

Note: There is no prior coverage for QMB unless income during a specific prior month is over the QMB limit and is within the SLMB income limit criterion.

Related Policy

Medicare Savings Programs, A-8000

Q-4210 Breast and Cervical Cancer Services Program

Revision 12-2; Effective June 1, 2012

Do not certify a person for a Medicare Savings Program if that person is receiving services through the Breast and Cervical Cancer Services (BCCS) program.

To receive services through the BCCS program, a person must be uninsured. As a result, insurance coverage from another Medicaid program or Medicare would stop that person from receiving services through the BCCS program.

The MSP EDG will be pended until MBCC denial is disposed by the TW advisor. The TW advisor will be notified of the pended MSP EDG by an Alert.

Q-4220 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

Q-4230 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

Q-4240 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

Q-4250 Reserved for Future Use

Revision 12-2; Effective June 1, 2012

Q-5000, Qualifying Individuals

Revision 24-3; Effective Sept. 1, 2024

The Qualifying Individuals (QIs) program pays only the Medicare premiums for people who meet all eligibility requirements.

QI has the same eligibility criteria as QMB except the person’s countable income must be at least 120% but less than 135% of the federal poverty level (FPL).

A person cannot be certified for any other Medicaid-funded program and the QI program at the same time. If eligible for both programs, the person must be given the opportunity to choose which benefit they prefer to receive. Document the person’s verbal or written choice in case comments, including the person’s choice between QI benefits and Community Attendant Services (CAS).

Related Policy

Medicare Savings Program Information, Appendix IX
Qualifying Individuals (QIs), A-8300
Medicare Savings Programs Overview, Q-1000
MSP Resource Limits, Q-1300
MSPs and Medicare Part B-ID, Q-1500
Qualified Medicare Beneficiaries, Q-2000
Medicare Savings Programs and Dual Eligibility, Q-4000

Q-5100, QI Benefits

Revision 09-4; Effective December 1, 2009

Authorized under 42 U.S.C. §1396a(a)(10)(E)(iv), the QI Program pays only Medicare Part B premiums to a person who is eligible for QI.

Q-5200, QI Income Limits

Revision 24-2; Effective June 1, 2024

Monthly income must be at least 120 percent FPL and less than 135 percent FPL.

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

Monthly Income Limits for the QI-1 Program

Time PeriodIndividual LimitCouple LimitDeeming*
March 1, 2024 to Present$1,506 to $1,695$2,044 to $2,300$605
March 1, 2023 to Feb. 29, 2024$1,458 to $1,640$1,972 to $2,219$579
March 1, 2022 to Feb. 28, 2023$1,359 to $1,529$1,831 to $2,060$531
March 1, 2021 to Feb. 28, 2022$1,288 to $1,449$1,742 to $1,960$511
March 1, 2020 to Feb. 28, 2021$1,276 to $1,436$1,724 to $1,940$504
March 1, 2019 to Feb. 29, 2020$1,249 to $1,406$1,691 to $1,903$497
March 1, 2018 to Feb. 28, 2019$1,214 to $1,366$1,646 to $1,852$486
March 1, 2017 to Feb. 28, 2018$1,206 to $1,357$1,624 to $1,827$470
March 1, 2016 to Feb. 28, 2017$1,188 to $1,337$1,602 to $1,803$466
March 1, 2015 to Feb. 29, 2016$1,177 to $1,325$1,593 to $1,793$468
March 1, 2014 to Feb. 28, 2015$1,167 to $1,313$1,573 to $1,770$457
March 1, 2013 to Feb. 28, 2014$1,149 to $1,293$1,551 to $1,745$452
March 1, 2012 to Feb. 28, 2013$1,117 to $1,257$1,513 to $1,703$446
March 1, 2011 to Feb. 29, 2012$1,089 to $1,226$1,471 to $1,655$429

*The deeming allocation amount is based on the difference between the couple and individual income limits.

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

Related Policy

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

Q-5400, QI Medical Effective Date

Revision 09-4; Effective December 1, 2009

Eligibility for QI coverage is determined for each calendar year. A person's QI eligibility may begin with the month of application. A person with QI coverage is eligible for three months prior medical coverage if all criteria are met. The three-month prior period cannot extend back into the previous calendar year.

The application file date and prior coverage months must be in the same calendar year. Example: If the application is filed in February, the only possible prior coverage month is January.

Q-5600, QI-2

Revision 12-2; Effective June 1, 2012

Authority for the QI-2 program under Public Law 105-33 expired on Dec. 31, 2002.

Q-6000, Qualified Disabled and Working Individuals – MC-QDWI

Revision 22-2; Effective June 1, 2022

A person with a disability who gets Social Security disability payments and free Medicare may work. If the person’s earnings exceed a certain amount over a time-period, the Social Security Administration (SSA) may stop the person’s Social Security benefits and free Medicare. Under Section 1818A of the Social Security Act, a person may pay the Medicare Part A premium if SSA denies the person’s free Medicare because of earnings.

Persons eligible for QDWI do not receive regular Medicaid benefits. They must be disabled working individuals entitled to Medicare Part A (hospital coverage). Medicaid will pay the Medicare Part A premiums for QDWIs.

SSI policy is used to determine eligibility for the Qualified Disabled and Working Individuals (QDWI) Program – MC-QDWI. To be eligible for QDWI coverage, a person must:

  • be under 65 years old;
  • be entitled to benefits under Medicare Part A;
  • not otherwise certified under any other Medicaid-funded program;
  • have a monthly income equal to or less than 200% of the federal poverty level; and
  • have no more than twice the countable resources allowed under the SSI program.

Resource Limits

  • Individual – $4,000
  • Couple – $6,000

Q-6100, QDWI Benefits

Revision 12-2; Effective June 1, 2012

Authorized under 42 USC §1396a(a)(10)(E)(ii), the QDWI Program pays only Medicare Part A premiums. A person cannot be eligible for regular Medicaid and QDWI coverage at the same time. The person does not receive a Your Texas Benefits Medicaid Card or Form H1027, Medical Eligibility Verification.

A person's QDWI eligibility begins in accordance with the coverage period described in §1818A of the Social Security Act (42 USC §1395i-2a(c)).

Q-6200, QDWI Income Limits

Revision 24-2; Effective June 1, 2024

Monthly income must be equal to or less than 200% of the FPL.

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

Monthly Income Limits for the QDWI Program

Time PeriodIndividualCoupleDeeming*
March 1, 2024 to Present$2,510$3,407$897
March 1, 2023 to Feb. 29, 2024$2,430$3,287$857
March 1, 2022 to Feb. 28, 2023$2,265$3,052$787
March 1, 2021 to Feb. 28, 2022$2,147$2,904$757
March 1, 2020 to Feb. 28, 2021$2,127$2,874$747
March 1, 2019 to Feb. 29, 2020$2,082$2,819$737
March 1, 2018 to Feb. 28, 2019$2,024$2,744$720
March 1, 2017 to Feb. 28, 2018$2,010$2,707$697
March 1, 2016 to Feb. 28, 2017$1,980$2,670$690
March 1, 2015 to Feb. 29, 2016$1,962$2,655$693
March 1, 2014 to Feb. 28, 2015$1,945$2,622$677
March 1, 2013 to Feb. 28, 2014$1,951$2,585$670
March 1, 2012 to Feb. 28, 2013$1,862$2,522$660
March 1, 2011 to Feb. 29, 2012$1,815$2,452$637
March 1, 2009 to Feb. 28, 2011$1,805$2,429$624
March 1, 2008 to Feb. 28, 2009$1,734$2,334$600
April 1, 2007 to Feb. 29, 2008$1,702$2,282$580
April 1, 2006 to March 31, 2007$1,634$2,200$566
April 1, 2005 to March 31, 2006$1,595$2,139$544
April 1, 2004 to March 31, 2005$1,552$2,082$530
Jan. 1, 2003 to March 31, 2004$1,497$2,020$523
Jan. 1, 2002 to Dec. 31, 2002$1,477$1,990$513
Jan. 1, 2001 to Dec. 31, 2001$1,432$1,935$503
Jan. 1, 2000 to Dec. 31, 2000$1,392$1,875$483
Jan. 1, 1999 to Dec. 31, 1999$1,374$1,844$470
Jan. 1, 1998 to Dec. 31, 1998$1,342$1,809$467
Jan. 1, 1997 to Dec. 31, 1997$1,315$1,769$454
Jan. 1, 1996 to Dec. 31, 1996$1,290$1,727$437
Jan. 1, 1995 to Dec. 31, 1995$1,245$1,672$427
Jan. 1, 1994 to Dec. 31, 1994$1,227$1,640$413
Jan. 1, 1993 to Dec. 31, 1993$1,162$1,572$410
Jan. 1, 1992 to Dec. 31, 1992$1,136$1,532$396
Jan. 1, 1991 to Dec. 31, 1991$1,104$1,480$376
July 1, 1990 to Dec. 31, 1990$1,047$1,404$357

* 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

Q-6300, QDWI Cost-of-Living Adjustment

Revision 16-2; Effective June 1, 2016

Recipients of QDWI do not receive Social Security benefits, therefore the cost-of-living adjustment (COLA) does not apply.

Q-6400, QDWI Medical Effective Date

Revision 09-4; Effective December 1, 2009

The medical effective date is influenced by whether the person enrolls for Medicare coverage during the initial enrollment period but before his present Medicare entitlement ends, after the initial enrollment period begins but after his entitlement ends, or following the initial enrollment period. Consider the date the person enrolled for continuation of his/her Medicare entitlement when determining the medical effective date (MED). The MED does not precede the earliest date the person is entitled to reinstatement of his Part A coverage. Otherwise, use the same procedures for determining the MED for all other MEPD programs (including three months prior coverage).

Example: The following chart may be used as a reference for the MED determination policies and examples.

Enrollment PeriodMonthActivities
Initial
Enrollment Period		April
May		Person notified his free Part A entitlement will end
 JuneEnd of person's free entitlement
 July
August
September		First month person meets QDWI criteria
General
Enrollment Period		January
February		QDWI coverage effective July 1
 MarchEnd of general enrollment period

The following applies when determining the MED:

  • The initial enrollment period for a person who has been notified that his free entitlement to Medicare Part A coverage will end is seven months. The enrollment period begins the month the person is notified.

    Example: A person is notified in April that his free entitlement to Part A coverage ends at the end of June. His initial enrollment period begins in the month of notification (April) and ends at the end of October. To reinstate his Part A coverage, he must enroll with SSA before the end of October. He then must apply with the department for QDWI benefits.
  • In the case of a person who enrolls in an initial enrollment period before meeting QDWI criteria and applies for QDWI benefits, the medical effective date is the first day of the month he meets the QDWI criteria.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in April and applies for and is determined eligible for QDWI benefits with the department in May. The earliest MED he can have for QDWI benefits is July 1 because it is the first month he meets QDWI criteria and is allowed to purchase Part A coverage.
  • If the person enrolls in the first month that he meets all QDWI criteria except for reinstatement (fourth month of the initial enrollment period), and applies for QDWI benefits, the MED is effective the first of the following month.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in July and applies for and is determined eligible for QDWI benefits in July. The earliest medical effective date he can have for QDWI benefits is Aug. 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If the person enrolls in the second month that he meets all QDWI criteria except for reinstatement (fifth month of the initial enrollment period) and applies for QDWI benefits, the MED is effective the second month after enrollment.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in August and applies for and is determined eligible for QDWI benefits in September. The earliest MED he can have for QDWI benefits is Oct. 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If the person enrolls in the third or fourth month that he meets all QDWI criteria except for reinstatement (sixth or seventh month of the initial enrollment period) and applies for QDWI benefits, the medical effective date is effective the first day of the third month following the month he enrolled.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He enrolls for reinstatement of his Part A coverage with SSA in September and applies for and is determined eligible for QDWI benefits in October. The earliest MED he can have for QDWI benefits is Dec. 1 because that is the first month he is entitled to reinstatement of his Part A coverage.
  • If the person enrolls during the general enrollment period, the medical effective date is always effective July 1.

    Example: A person is notified in April that his free entitlement to Medicare Part A coverage ends at the end of June. He does not enroll during the initial enrollment period and decides to enroll during the general enrollment period, from January through March 31, of the next year. The earliest MED date he is allowed is the July 1 following his enrollment.

Q-6500, General SSA Procedures Involving Potential QDWIs

Revision 09-4; Effective December 1, 2009

The Social Security Administration notifies disabled persons whose Social Security disability payments have ceased and whose Medicare coverage is about to cease because of earnings. A seven-month initial enrollment period begins with the month of notification. During this period, the person may enroll to pay the Medicare premium himself or he may contact the department to have his eligibility determined for QDWI benefits. If he does not take either of these actions, his Medicare coverage ends and he must wait until the next general enrollment period to enroll for Medicare coverage.

Reminder: Remember that entitlement to Medicare Part A is one of the eligibility criteria for receiving QDWI benefits.

 

Q-6600, QDWI Application Procedures

Revision 09-4; Effective December 1, 2009

Q-6610 Medicare Part A Entitlement

Revision 09-4; Effective December 1, 2009

Ask the person if he/she is entitled to Medicare Part A benefits.

  • If the person is currently enrolled, verify by checking:
    • the person's Medicare card;
    • a TPQY inquiry; or
    • the letter from the Social Security Administration (SSA) notifying the person of the imminent termination of Part A.
  • If the person has been entitled but is not currently enrolled, determine when his/her entitlement ended.
    • If entitlement has ended, but the person can still enroll during his/her initial enrollment period, refer him to SSA to begin enrollment procedures. He or She must obtain proof of enrollment from SSA.
    • If both entitlement and the initial enrollment period have ended, the person cannot be eligible for QDWI benefits until after enrolling with SSA during the general enrollment period (January through March of each year). QDWI benefits begin in July of the year of enrollment.