Medicaid and Extra Help

The distinction between the Medicare Savings Program and Medicaid is explained in this blog post. It also explains the distinction between a Qualified Medicare Beneficiary (QMB) and a Qualified Medicare Beneficiary Plus (QMB +). We’ll go over how MAPD, PDP, and Medicare Supplement plans work with the programs. We’ll also go through the types of drug assistance options.

-QMB (Qualified Medicare Beneficiary), SLMB (Specified Low-Income Medicare Beneficiary), QI (Qualifying Individual), and QDWI (Qualified Disability Waiver) are all terms used to denote levels of assistance below full Medicaid (Qualified Disabled Working Individual). Medicaid is also known as QMB +.

MSP programs cover the cost-sharing portion of Medicare-approved benefits (Medical and Drug). The federal government funds these programs, which are then overseen by each state.

What are the benefits of MSP programs?

MSP does not cover any benefits that are not covered by Medicare. On the other hand, they are covered by the full Medicaid program: Preventative vision, dentistry, non-skilled home health care, transportation, incontinence supplies, and other benefits are not covered by Medicare.

What different levels of MSP mean and what are their eligibility criteria?

QMB+ is used for Medicaid that provides health coverage to more than 76 million Americans, including low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. (For more info see Medicaid | Medicaid )

  • – The Qualified Medicare Beneficiary Program is one of four Medicare Savings Programs that allows low-income Medicare beneficiaries to get assistance from their state in paying their Part A and Part B premiums and cost-sharing. On QMB, there are over 7 million users. Who qualifies for QMB? Individual monthly income limits are $1094 and $1472 for married couples, respectively. Individual resource limits are $7970 and $11960 for married couples.
  • – The Specified Low-Income Medicare Beneficiary Program is a state program that assists people with limited income and resources in paying their Part B premiums. Income and resource constraints for SLMB eligibility Individual monthly income limits are $1308, married couple monthly income limits are $1762, and individual resource limits are $7970 and married couple resource limits are $11960 in 2021.
  • – The Qualifying Individual Program is a state program that assists people with limited income and resources in paying their Part B premiums. Every year, people must apply for QI benefits. QI applications are processed on a first-come, first-served basis, with persons who received QI benefits the previous year receiving preference. If you qualify for Medicaid, you will not be eligible for QI benefits.

Individual monthly income limit of $1469, married couple monthly income limit of $1980, individual resource limit of $7970, married couple resource limit of $11960 are the QI income and resource limits.

  • Qualified Disabled and Working Individuals (QDWI) Program helps pay the Part A premium. People qualify if: have a disability, working, lost Social Security disability benefits and premium-free Part A because returned to work.

QDWI income and resource limit:

Individual monthly income limit – $4379, married couple monthly income limit – $5892, individual resource limit – $4000, married couple resource limit – $6000.

-What are the resource constraints for the Medicare Savings Program? – Countable resources: Money in a checking or savings account, stocks, and bonds.

Home, one car, burial plot, furniture, up to $1500 for burial expenses if set aside, and other household and personal things are not included. If you want to apply for Medicare Savings Programs, you must respond yes to the following three questions: 1. Do you have Part A coverage or are you eligible for it? 2. Is your income projected to be at or below the income restrictions for any of the programs indicated above in 2022? 3. Do you have limited resources that fall below the limits? To see if they qualify for a Medicaid Savings Program, the person can contact their state Medicaid program.

If a person qualifies for the QMB, SLMB, or QI program, he automatically qualifies to get extra help (also called LIS) paying for Medicare drug coverage.

Extra Help may be available to anyone who fulfill specific income and resource requirements. This program assists beneficiaries with their Medicare drug coverage expenditures, such as plan premiums, deductibles, and copays or coinsurance while filling prescriptions.

If a person qualifies for Extra Help, how much would he pay?

Plan premiums and deductibles: A person’s plan premium and yearly deductible may be less or none depending on his income level (an amount he must pay before his plan starts to pay).

Copays and coinsurance: By 2022, prescription expenses will be no more than (cap even in donut hole):

  • $3.95 for each generic drug
  • $9.85 for each brand-name covered drug

Do I qualify for Extra Help?

In 2022, you may qualify if you have up to $1,719 in monthly income ($2,309 for a married couple) and up to $15,510 in resources ($30,950 for a married couple).

  • Medicaid and MSP levels qualify for help with prescriptions (called ‘extra help or LIS’). For standalone PDP and MAPD plans, LIS covers the drug premium: Only each state has the authority to set a benchmark premium. Even if there is a penalty, all levels fund Medicare Part B premiums. Medicare Part A (if they don’t have free Part A) and Part B premiums, as well as Part A and B penalties, are covered by QMB and QMB Plus. They also cover late enrollment part D fines and pay for drug premiums up to the benchmark, limit copays even in the donut hole, and pay for drug premiums up to the standard.
  • On a (standard or dual) MAPD plan, QMB and QMB+ cover cost share that Medicare does not cover, as well as copays. MAPD enrollees will not pay copays, or any other cost share listed in the benefits of the plan. The programs will cover cost share as long as the benefits would otherwise be covered to some extent by the MAPD plan. It will not help with out of network doctors on an HMO MAPD or Dual HMO MAPD. The program will only help with medications that are in the formulary of the MAPD or PDP plan.

Medicare saving program and Medicare supplement

  • Agents are not supposed to enroll QMB+
  • Agents can enroll those with the other levels although it is not common with a QMB
  • The help will apply to the stand-alone drug plan
  • Up to the benchmark premium on the PDP
  • Range from $22 to $47 a month depending on the state

Anyone that has any MSP level of help can make a plan change using a LIS SEP (Special Election Period) one time each quarter for the first 3 quarters of the year:

  • Existing people with help cannot make a one-time change when they get help regardless of when it is. Can only change in the first three quarters after that
  • This applies to MAPD (regular and dual) and drug plans

QMB+/Medicaid get extra benefits not covered by Medicare. QMB, SLMB, QI do not get extra benefits

  • MAPD or Dual MAPD can give them those benefits such as: dental, vision, OTC, transportation, hearing, etc…
  • QMB+ and QMB will pay copays and cost share for both regular MAPD and Dual MAPD plans
  • If the drug is not in the plan formulary, the help program will not pay

QMB+ and QMB will not pay with an out of network doctor on an HMO MAPD (regular or dual)

Medicare agents should use the special election periods available to people with any level of help.

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