Qualified Medicare Beneficiary (QMB) (S03)

Created on: 
Apr 21 2016

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What is the Qualified Medicare Beneficiary (S03) medical program?

S03 medical is a Medicare Savings Program (MSP) that helps pay some of the client's Medicare costs such as: Medicare Part A & B premiums, co-insurance and deductibles. For additional information, see Apple Health eligibility manual - WAC 182-517-0320 Medicare savings and state-funded Medicare buy-in programs cover some client costs.

How long is the Qualified Medicare Beneficiary (S03) certification period?

The default certification period for an S03 Assistance Unit (AU) is 12 months.

Note: The S03 AU does not have a certification end date if the client also receives SSI Categorically Needy (S01) medical.

S03 coverage begins the first of the month following the month eligibility is determined for the program and the client is Medicare Part B eligible. The application month is denied with Reason Code 279 - QMB Start Date.

For more information on certification periods, see Apple Health eligibility manual - WAC 182-504-0025 Medicare savings program certification periods.

When is a Medicare Savings Program (MSP) automatically opened?

ACES automatically opens Qualified Medicare Beneficiary (S03) medical for:

  • Supplemental Security Income (SSI) recipients based on information received from the Social Security Administration (SSA).
  • SSI-related recipients on one of the programs listed below based on Third Party Liability (TPL) information received on the ProviderOne interface:
    • G03 (Categorically Needy (CN) Alternate Living Facility)
    • G95 (Medically Needy (MN) Alternate Living Facility)
    • G99 (MN Alternate Living Facility with Spenddown)
    • L02 (CN SSI Related Long Term Care)
    • L22 (CN SSI HCB Waiver)
    • L95 (LTC MN or Hospice)
    • L99 (LTC MN or Hospice with Spenddown)
    • S02 (SSI Related CN)
    • S95 (MN SSI Related)
    • S99 (MN SSI Related with Spenddown)
NOTE: If a client is pending on one of the medical coverage groups listed above, a Barcode tickle generates with the message “Client is Medicare Eligible (Date); Review for MSP”.

Alert 245 - AUTO-OPEN NOT POSSIBLE REVIEW FOR MEDICAID/MEDICARE ELIGIBILITY is sent to the user of record on cases where the system is unable to auto open because of a discrepancy in name, birth date or Social Security Number.

What if the client’s countable income exceeds 100% of the Federal Poverty Level (FPL)?

If the client's countable income exceeds 100% of the FPL, one of the following may happen:

  • Qualified Medicare Beneficiary (S03) trickles to Specified Medicare Beneficiary (S05) medical when the countable income is greater than 100% but less than 120% of the FPL.
  • S03 trickles to Qualified Individual (S06) medical when the countable income is greater than 120% but less than 135% of the FPL.

For more information on income standards, see Apple Health eligibility manual - WAC 182-517-0100 Medicare savings programs - Monthly income standards.

What if the client is applying for Long Term Care (LTC) and Qualified Medicare Beneficiary (S03) medical?

When the client is applying for LTC and S03 medical, finalize the LTC medical application before finalizing the S03 Assistance Unit (AU). Clients who are eligible for LTC medical are also eligible for S03; see Apple Health eligibility manual - WAC 182-517-0310 Eligibility for federal Medicare savings and state-funded Medicare buy-in programs.

The income standard is higher for LTC medical programs so if you finalize the S03 prior to finalizing the LTC medical AU, the S03 could incorrectly trickle to Specified Medicare Beneficiary (S05) or Qualified Individual (S06) medical or deny for Reason Code 301 - Exceeds Income Standard.

Online Processing

Who is eligible to receive Qualified Medicare Beneficiary (S03) medical?

A person who meets the criteria in the following may be eligible for S03 medical:

NOTE: A client who is eligible for Supplemental Security Income (SSI) and Medicare is always eligible for S03 medical when the Third Party Liability page is updated with an active Medicare Part A or Part B policy that has an end date greater than the benefit month being processed or is blank.

​How do I screen Qualified Medicare Beneficiary (S03) medical?

To screen an S03 Assistance Unit (AU), take the following steps:

  1. From the Welcome back page in aces.online, click Screen New Application.
  2. On the Applicant page, complete the following fields:
  • Applicant Name field - Enter the [head of household’s (HOHs) first, middle initial, and last name].
  • Residential Address section - Enter the [head of household's residential address].
    • ACES attempts to verify both the Residential and Mailing Addresses, in real time, through a United States Postal Services (USPS) software program called Finalist when the street address, city, state, and zip code are entered.
  • If the applicant has a mailing address, click the box next to Mailing Address same as above to remove the checkmark and enter the applicant’s mailing address.
  • Click the Next button.
  1. On the Address Validation page, take any necessary steps to complete the address validation process. For more information, see Screening - Address Validation. Click the Next button.
  2. On the Programs page, complete the following fields:
  • In the Programs section, click the checkbox next to Medical.
  • In the Program Determination Criteria section, click the checkbox next to Medicare Part A Eligible.
  • Click the Next button.
  1. Use the Add Member - Search Criteria and Add Member - Client Matches pages to enter the HOH and any other clients to the AU.
  2. Complete the screening process following the instructions in How do I screen an application for a client?

How do I process a pending Qualified Medicare Beneficiary (S03) Assistance Unit (AU)?

To process a pending S03 AU, take the following steps:

  1. On the Assistance Unit Detail page, use one of the following financial responsibility codes to complete the Financial Responsibility field(s):
  • Applicant (PN) for the applicant and an applying spouse (if applicable).
  • Ineligible Spouse (SP) for an ineligible or non-applying spouse.
  • Child - SSI/Of SSI-related Parent/Used for HH size (SC) for any children.
  1. On the Client Details page, complete the following fields:
  • Marital Status field - Select the client's marital status from the drop down menu.
  • Living Arrangement field - Select the appropriate living situation from the drop down menu.
  • Disability/Incapacity Type field - Select the applicant's disability type from the drop down menu.
  • Approval Source field - Select the disability approval source from the drop down menu.
  • Approval Date field - Enter the [disability approval date].
  • Established Date field - Enter the [disability established date].
  • End Date: [MM/YYYY] field - Enter the [date the disability approval ends], if applicable.
Note: If S03 program eligibility is based on age, coding the Disability / Incapacitated / Psychiatric section is optional.
  1. On the Third Party Liability page, complete the following:
  • Organization Code field - Enter [MEDA] or [MEDB].
Note: Complete a second Third Party Liability page if the client has both Medicare Part A and Medicare Part B.
  • Policy Effective Dates field - Enter [Medicare Enrollment Date].
  • Policy Number field - Enter [Social Security claim number].
  1. After committing the interview data, for all pending months follow the instructions in How do I complete Process Application Months?
  2. After all pending months have been processed; follow the instructions in the Finalize Application chapter to complete the S03 eligibility determination.

How do I determine eligibility for a married couple when one or both clients receive Supplemental Security Income (SSI)?

When a Qualified Medicare Beneficiary (S03) Assistance Unit (AU) contains a married couple who are both entitled to Medicare with income type SSI Benefits (SI) entered on the Unearned Income page, both are S03 eligible.

When an S03 AU contains a married couple who are both entitled to Medicare; however, only one is receiving SSI Benefits (SI) income and the other is receiving SSA Retirement/Disability (SS) income:

  • Clients with SSI income are approved for S03.
  • Clients with Social Security Administration (SSA) income are approved for S03 when their income and resources are below the S03 standard (based on the number of persons in the AU without SSI income).
  • Clients with SSA income who have income or resources exceeding the S03 standard are closed or denied for the appropriate Reason Code 301 - Exceeds Income Standard or 401 - Over Resources.
Note: The denied client should then be screened on their own AU to determine their eligibility for either Specified Medicare Beneficiary (SLMB) (S05) or Qualified Individual (QI-1) (S06) medical coverage. In this situation, code the SSI spouse with a Financial Responsibility code of Non-Member (NM) on the non-SSI client’s AU. For more information, see How do I screen Qualified Medicare Beneficiary (S03) medical?
  • If the head of household (HOH) has income or resources exceeding the S03 standard, but the AU contains another member who is S03 eligible, the HOH’s Financial Responsibility code flips to Non-Member (NM) with the appropriate reason code.

Mainframe Processing

Who is eligible to receive Qualified Medicare Beneficiary (S03) medical?

A person who meets the criteria in the following may be eligible for S03 medical:

NOTE: A client who is eligible for Supplemental Security Income (SSI) and Medicare is always eligible for S03 medical when the TPL1 screen is updated with an active Medicare Part A or Part B policy that has an end date greater than the benefit month being processed or is blank.

How do I process a pending Qualified Medicare Beneficiary (S03) Assistance Unit (AU)?

To process a pending S03 AU, take the following steps:

  1. On the AMEN screen, select Option [O] - Interview.
  2. On the STAT screen, use one of the following Finl Resp codes to complete the Finl Resp field(s):
  • [PN] - Applicant for the applicant and an applying spouse (if applicable).
  • [SP] - Ineligible Spouse / Non-Applying Spouse for an ineligible or non-applying spouse.
  • [SC] - Child used to determine family size for any children.
  1. On the DEM1 screen, complete the following fields:
  • Living Arrangement field - Enter the [appropriate valid value based on the client’s situation].
  • Marital Status field - Enter the [client's marital status].
  1. On the DEM2 screen, complete the following fields:
  • Dis/Incp/ESRD field - Enter the applicant’s [Dis/Incp/ESRD Type].
  • Approv Source field - Enter the [approval source].
  • Approv Date (MM DD YY) field - Enter the [disability approval date].
  • Estab Date (MM DD YY) field - Enter the [disability established date].
  • End Date (MM YY) field - Enter the [date the disability approval ends], if applicable.
Note: If S03 program eligibility is based on age, coding the Disability/Incapacity section is optional.
  1. On the TPL1 screen, complete the following:
  • Org field - Enter [MEDA] or [MEDB].
Note: Complete a second TPL1 screen if the client has both Medicare Part A and Medicare Part B.
  • Policy Effective Dates From field - Enter [Medicare Enrollment Date].
  • Policy Number field - Enter [Social Security claim number].
  1. After committing the interview data, for all pending months follow the instructions in How do I complete Process Application Months?
  2. After all pending months have been processed; follow the instructions in the Finalize Application chapter to complete the S03 eligibility determination.

How do I determine eligibility for a married couple when one or both clients receive Supplemental Security Income (SSI)?

When a Qualified Medicare Beneficiary (S03) Assistance Unit (AU) contains a married couple who are both entitled to Medicare with income type [SI] - SSI Payment entered on the UNER screen, both are S03 eligible.

When an S03 AU contains a married couple who are both entitled to Medicare; however, only one is receiving [SI] - SSI Payment income and the other is receiving [SS] - Social Security income:

  • Clients with SSI income are approved for S03.
  • Clients with Social Security Administration (SSA) income are approved for S03 when their income and resources are below the S03 standard (based on the number of persons in the AU without SSI income).
  • Clients with SSA income who have income or resources exceeding the S03 standard are closed or denied for the appropriate Reason Code 301 - Exceeds Income Standard or 401 - Over Resources.
Note: The denied client should then be screened on their own AU to determine their eligibility for either Specified Medicare Beneficiary (SLMB) (S05) or Qualified Individual (QI-1) (S06) medical coverage. In this situation, code the SSI spouse with a Financial Responsibility code of [NM] - Not Related and Not Financially Responsible to the Applicant on the non-SSI client’s AU. For more information, see How do I screen Qualified Medicare Beneficiary (S03) medical?
  • If the head of household (HOH) has income or resources exceeding the S03 standard, but the AU contains another member who is S03 eligible, the HOH’s Financial Responsibility code flips to [NM] - Not Related and Not Financially Responsible to the Applicant with the appropriate reason code.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.