Federal law requires that state Medicaid programs pay Medicare Part A and/or Part B premiums and, in some cases, Medicare coinsurance and deductibles for certain elderly and disabled people through a Medicare Savings Program. These individuals are designated as follows:
- Qualified Medicare Beneficiary (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Qualified Individual (QI)
- Qualified Disabled Working Individual (QDWIs)
To receive assistance with Medicare-related costs, the following criteria must be met:
- Be entitled to Medicare (including those age 65 and older, as well as younger individuals who are entitled to Medicare)
- Have low income
- Have few personal resources
Medicare Savings Programs primary coverage categories include the following:
- QMB-Only – The member's benefits are limited to payment of the member's Medicare Part A premiums (if member is not entitled to free Part A) and Part B premiums, as well as deductibles and coinsurance or copayment for Medicare-covered services. Claims for services covered by Medicare (including Medicare-covered services provided through a Medicare Advantage Plan) may cross over to Medicaid for additional payment consideration. Claims for services not covered by Medicare are denied as Medicaid noncovered services. When the Indiana Health Coverage Programs (IHCP) Eligibility Verification System (EVS) identifies a member as having only Qualified Medicare Beneficiary coverage (without also having Full Medicaid or Package A coverage), the provider should contact Medicare to confirm medical coverage. Failure to confirm coverage may result in a claim denial because Medicare benefits may have been discontinued or recently denied.
- QMB-Also – The member's benefits include payment of the member's Medicare premiums, deductibles and coinsurance or copayment on Medicare-covered services plus full Medicaid benefits (either through Traditional Medicaid or Indiana PathWays for Aging). When the EVS identifies a member as having Qualified Medicare Beneficiary coverage and also Full Medicaid or Package A coverage, claims for services covered by Medicare (including Medicare-covered services provided through a Medicare Advantage Plan) my cross over to Medicaid for additional payment consideration. Claims for services not covered by Medicare may be submitted to the IHCP as regular Medicaid claims (not as crossover claims).
- SLMB-Only – The member's benefits are limited to payment of the member's Medicare Part B premium only. When the EVS identifies a member as having only Specified Low-Income Medicare Beneficiary coverage (without also having Full Medicaid or Package A coverage), the provider should contact Medicare to confirm medical coverage. Failure to confirm coverage may result in a claim denial because Medicare benefits may have been discontinued or recently denied.
- SLMB-Also – The member's benefits include payment of the member's Medicare Part B premium in addition to full Medicaid benefits (either through Traditional Medicaid or Indiana PathWays for Aging). When the EVS identifies a member as having Specified Low-Income Medicare Beneficiary coverage and also Full Medicaid or Package A coverage, claims for for services covered by Medicare (including Medicare-covered services provided through a Medicare Advantage Plan) may cross over to Medicaid for additional payment consideration. Claims for services not covered by Medicare may be submitted to the IHCP as regular Medicaid claims (not as crossover claims).
- QI – The member's benefit is payment of the member's Medicare Part B premium. The EVS identifies this coverage as Qualified Individual.
- QDWI – The member's benefit is payment of the member's Medicare Part A premium. The EVS identifies this coverage as Qualified Disabled Working Individual.
Note: IHCP members with Full Medicaid or Package A coverage who are enrolled in Medicare but who do not qualify for a Medicare Savings Program are known as Other Full Benefit Dual Eligible (Other FBDE) members. The IHCP provides the same level of coverage for Other FBDE members as it provides for SLMB-Also members.