Revision 09-4; Effective December 1, 2009

§359.101. Purpose and Scope.

(a) This chapter describes the assistance available and eligibility requirements for the Medicare Savings Program. Authorized under 42 U.S.C. §1396a(a)(10)(E), the Medicare Savings Program uses Medicaid funds to help eligible persons pay for all or some of their out-of-pocket Medicare expenses, such as premiums, deductibles, or coinsurance.

(b) The Texas Health and Human Services Commission (HHSC) manages the Medicare Savings Program, which consists of the following:

(1) the Qualified Medicare Beneficiary (QMB) Program;

(2) the Specified Low-Income Medicare Beneficiary (SLMB) Program;

(3) the Qualified Individual (QI) Program; and

(4) the Qualified Disabled and Working Individual (QDWI) Program.

(c) Nothing in these rules shall be construed to violate the maintenance of eligibility requirements of section 5001 of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and make eligibility standards, methodologies, or procedures under the Texas State Plan for Medical Assistance (or any waiver under section 1115 of the Social Security Act (42 U.S.C. §1315)) more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that were in effect on July 1, 2008.

§359.103. Qualified Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(i), the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums, deductibles, and coinsurance for a person who meets the requirements of this section. A person receiving Medicaid may also receive QMB benefits if the person meets the requirements of this section.

(b) To be eligible for QMB coverage, a person must:

(1) be entitled to benefits under Medicare Part A; and

(2) meet income and resources requirements in 42 U.S.C. §1396d(p).

(c) A person is not eligible for QMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's QMB eligibility begins on the first day of the month after the month the person is certified for QMB benefits.

(e) A person with QMB coverage is not eligible for three months prior medical coverage.

§359.105. Specified Low-Income Medicare Beneficiary Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iii), the Specified Low-Income Medicare Beneficiary (SLMB) Program pays only Medicare Part B premiums for a person who meets the requirements of this section. A person receiving Medicaid may also receive SLMB benefits if the person meets the requirements of this section.

(b) To be eligible for SLMB coverage, a person must meet the eligibility criteria for QMB coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have an income that is greater than 100% but less than 120% of the federal poverty level.

(c) A person is not eligible for SLMB coverage if the person:

(1) is in the custody of penal authorities as defined in 42 C.F.R. §411.4(b); or

(2) is over 20 years of age and under 65 years of age and resides in an institution for mental diseases.

(d) A person's SLMB eligibility may begin with the month of application.

(e) A person with SLMB coverage is eligible for three months prior medical coverage, if all criteria are met.

§359.107. Qualifying Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(iv) the Qualifying Individual (QI) Program pays only Medicare Part B premiums to a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QI coverage at the same time.

(b) To be eligible for QI coverage, a person must meet the eligibility criteria for Qualified Medicare Beneficiary coverage in §359.103(b) of this chapter (relating to Qualified Medicare Beneficiary Program), except the person must have income that is at least 120% but less than 135% of the federal poverty level.

(c) Eligibility for QI coverage is determined for each calendar year.

(d) A person's QI eligibility may begin with the month of application.

(e) 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.

§359.109. Qualified Disabled and Working Individual Program.

(a) Authorized under 42 U.S.C. §1396a(a)(10)(E)(ii), the Qualified Disabled and Working Individual (QDWI) Program pays only Medicare Part A premiums for a person who meets the requirements of this section. A person cannot be eligible for regular Medicaid and QDWI coverage at the same time.

(b) To be eligible for QDWI coverage, a person must:

(1) be under 65 years of age;

(2) be entitled to benefits under Medicare Part A;

(3) not otherwise be eligible for Medicaid;

(4) have a monthly income equal to or less than 200% of the federal poverty level; and

(5) have no more than twice the countable resources allowed under the Supplemental Security Income (SSI) program, as described in §1611 of the Social Security Act (42 U.S.C. §1382).

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

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.

Revision 23-1; Effective March 1, 2023

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) and are updated in January of each year:

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

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

Date Range	Individual	Couple
Jan. 1, 2023 to Present	$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 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

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

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 23-2; Effective June 1, 2023

Monthly income must be not more than 100 percent FPL.

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

Monthly Income Limits for the QMB Program

Date Range	Individual	Couple	Deeming*
March 1, 2023 to Present	$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

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 13-4; Effective December 1, 2013

If a denied SSI recipient applies for Medicaid under an MEPD program, verify whether the individual was also receiving QMB benefits at the time of the SSI denial by viewing the individual’s Medicaid History or Eligibility History in TIERS Inquiry. Verification also can be obtained by SOLQ/WTPY.

If a person is eligible for QMB and is applying for MC-QMB, enter the Continuous QMB Begin Month in the Program – Individual page in the system of record. This ensures continuous QMB coverage.

Examples:

• The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is being certified under ME-Pickle and MC-QMB.
• The last day of SSI with QMB coverage is Jan. 31, 20XX. The person is certified under MC-QMB.

Technically, there is no limit as to how far back continuous QMB coverage may be given. However, system limitations will not allow Medicare Part B buy-in reimbursement to begin any earlier than two full fiscal years (with September considered the start of a fiscal year). The earliest buy-in date is based on the date that the buy-in process is successfully completed (not the eligibility specialist's decision date, the person's medical effective date [MED], or QMB effective date).

Examples:

• SSI/QMB coverage denied Dec. 31, 2007
  Form H1200, Application for Assistance – Your Texas Benefits, filed April 7, 2010
  Eligibility determined on May 15, 2010, for continuous QMB; QMB MED = Jan. 1, 2008; buy-in process completed on July 15, 2010; buy-in effective January 2008 (current full fiscal year does not end until August 2010; earliest full fiscal year began September 2007)
• SSI/QMB coverage denied Dec. 31, 2007
  Form H1200 filed Aug. 15, 2010
  Eligibility determined on Sept. 11, 2010, for continuous QMB; QMB MED = Jan. 1, 1998; buy-in process completed on Nov. 15, 2010; buy-in effective September 2008 (current full fiscal year began September 2010; earliest full fiscal year began September 2008)

If the QMB medical effective date precedes the earliest available buy-in date, the person can receive Medicaid coverage for Medicare co-payments and deductibles for the entire period established by the medical effective date. Buy-in coverage would begin later. A person may elect not to have continuous coverage if the medical effective date will not provide buy-in for the entire period and the person does not have any claims to cover or be reimbursed.

What is not considered continuous QMB:

• QMB recipient was denied in error because income was incorrectly counted in the budget. The case needs to 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. These individuals cannot have continuous coverage if they reapply and are again eligible for QMB. The QMB effective date would be 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 needs to be corrected to add the missing coverage the recipient is entitled to receive.
• QMB recipient was denied at redetermination for no packet received. At reapplication, this is not a continuous QMB, as the denial was valid. The QMB effective date would be the first of the month after disposition.

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

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.

Revision 23-2; Effective June 1, 2023

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 Period	Range/Limit for Individuals	Range/Limit for Couple	Deeming*
March 1, 2023 to Present	$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.

SLMB uses the same resource limits as QMB and QI.  

Related Policy

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

Revision 20-3; Effective September 1, 2020

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.

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.

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.

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

 

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.

Revision 23-2; Effective June 1, 2023

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

QI-1s	Individuals (income at least, but less than)	Couples (income at least, but less than)	Deeming*
March 1, 2023 to Present	$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

Revision 20-3; Effective September 1, 2020

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.

Revision 12-2; Effective June 1, 2012

Revision 12-2; Effective June 1, 2012

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

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)).

Revision 23-2; Effective June 1, 2023

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 Period	Person	Couple	Deeming*
March 1, 2023 to Present	$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
Jul 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

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.

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 Period	Month	Activities
Initial Enrollment Period	April May	Person notified his free Part A entitlement will end
	June	End of person's free entitlement
	July August September	First month person meets QDWI criteria
General Enrollment Period	January February	QDWI coverage effective July 1
	March	End 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.

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.

 

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/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.

Revision 12-2; Effective June 1, 2012