Income as
of 2023*
2023*
A premium
(when
Part B
premiym
Parts A &
B cost
Medicaid
coverage**
Couple:
Couple:
Medicaid
by state
by state
state****
state****
* The Centers for Medicare & Medicaid Services (CMS) releases the income and resource limits for all states and D.C annually. The income
limits for the MSPs include a standard disregard of $20 and for QDWI, earned income disregards. The asset limit calculation for QMBs,
SLMBs, and QIs is 3 times the SSI resource limit, adjusted annually by increases in the Consumer Price Index (effective January 1, 2010).
States can effectively raise the federal floor for income and resources standards under the authority of section 1902(r)(2) of the Social Security
Act, which generally permits state Medicaid agencies to disregard income and/or resources that are counted under supplemental security
income (SSI) financial eligibility methodologies. Some states have used the authority of section 1902(r)(2) of the Act to effectively eliminate
the asset test for the MSP groups. Higher income limits apply for Alaska and Hawaii.
** “Full-benefit” Medicaid coverage generally refers to coverage for a range of items and services, beyond coverage for Medicare
premiums and cost-sharing, that certain individuals are entitled to when they qualify under certain eligibility categories included in the State
Medicaid Plan (state plan). Individuals who are QMB/SLMB “plus” receive full-benefit Medicaid in addition to coverage of some or all
their Medicare Parts A and B expenses. Individuals who receive full-benefit Medicaid only are entitled to Medicare Part A and/or enrolled
in Part B, and qualify for full-benefit Medicaid benefits, but not the QMB or SLMB groups.
*** While individuals enrolled in QMB do not pay Medicare deductibles, coinsurance, or copays, they may have a small Medicaid copay for
certain Medicaid-covered services.
**** States pay the Part B premiums if they include all Medicaid eligibility groups in their buy-in agreement with CMS.
***** Beneficiary pays no more than amount allowed by the state plan for services covered by both Medicare and Medicaid. Also, all Medicare
providers (regardless of Medicaid participation) must accept the Medicare-allowed amount (“Medicare assignment”) as payment in full for Part B
services furnished to dual eligible beneficiaries.
Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only – also known as QMB
“partial benefit”) are enrolled in Medicare Part A (including premium Part A on an actual or conditional
basis), have income at or below 100% of the federal poverty level (FPL) and resources that do not exceed
three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation, and
are not otherwise eligible for full-benefit Medicaid coverage. Medicaid pays their Medicare Part A
premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for Medicare
Parts A and B cost-sharing amounts, including deductibles, coinsurance and copays.
Providers can bill Medicaid programs for these amounts, but states have the option to reduce or
eliminate the state’s Medicare cost-sharing payments by adopting policies that limit payment to the lesser of
(a) the Medicare cost sharing amount, or (b) the difference between the Medicare payment and the Medicaid
rate for the service.
QMBs with full–benefit Medicaid (QMB Plus) meet the QMB-related eligibility requirements described
above and the eligibility requirements for a separate “categorical” eligibility group covered under the state
Medicaid plan. In addition to the coverage for Medicare premiums and cost-sharing described above, QMB
“Plus” individuals are entitled to the full range of Medicaid benefits applicable to the separate eligibility
group for which they qualify. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B
premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost sharing amounts,
including deductibles, coinsurance, and copays. Providers can bill Medicaid programs for these amounts,
but states have the option to reduce or eliminate the state’s Medicare cost sharing payments by adopting
policies that limit payment to the lesser of (a) the Medicare cost sharing amount, or (b) the difference
between the Medicare payment and the Medicaid rate for the service. QMBs with full-benefit Medicaid pay
no more than the Medicaid coinsurance (if applicable) for services covered in the state plan (i.e., care that is
furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not
Medicare, cover).