An official State of Texas website.
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.