PM 06-12-02-a.

  1. (FCRC) Give Application for Payment of Medicare Premiums, Deductibles and Coinsurance (Form 2378M), to each person who wants to apply for QMB only.
  2. (FCRC) Give applicant informational brochures, including:
    • Medical Assistance and Third Party Liability (Form 2875); and
    • Medicaid Payment of Medicare Cost Sharing Expenses (Form 3120).
  3. (FCRC) Explain applicant's right to also apply for cash and/or medical.

    NOTE: If applicant wants to apply for cash and/or medical and QMB, complete screening portion of Application for Financial Assistance - Medical Assistance - Food Stamps (Form 2378C). 

  4. (FCRC) Receive signed Form 2378M.
    1. Complete mail-in screening process through AIS.
    2. Register application as a Category 91, 92, or 93.

      NOTE: When Form 2378M is registered, only QMB benefits can be approved. A question: "Is this an application for QMB only?" is included in the screening process to help identify applications for QMB only. 

  5. (FCRC) Review application for completeness and proof of Medicare Part A eligibility, such as a copy of a Medicare card or SSA award letter showing Part A eligibility.
    1. Request information from applicant when required information is missing.
    2. Send client the Instructions to Client - Medical Payment of Medicare Premiums, Deductibles and Coinsurance (Form 267M), to confirm a verbal request for information and to request missing information when application was received in mail.
    3. Request that information be provided in 10 calendar days.
    4. Keep copy of Form 267M in case record.
    5. Assist client, if needed, in getting verification of Part A enrollment or any other required information.

      NOTE: Initiate SOLQ if client asks for help with verification of Part A.

  6. (FCRC) Deny application if applicant:
    • does not respond to Form 267M within 10 days, or
    • is not eligible for Part A.
    1. Enter Code 00 in Item 39 of Form 552. Code 00 shows a centrally generated denial notice, Form 360C, will be sent.
  7. (FCRC) Determine the value to nonexempt assets by using the Qualified Medicare Beneficiary (QMB) - Computation Sheet (Form 2382M).
    1. Deny application if nonexempt assets are more than QMB asset limit.
    2. Enter Code 00 in Item 39 of Form 552 to send Form 360C, a centrally generated denial notice.
  8. (FCRC) Use Form 2382M to compare countable monthly income to income limit. Use the $25 community case income exemption, if it applies.

    NOTE: Use the one person standard for clients who have been living in a long term care facility for at least one month. 

    1. If applicant is income ineligible for QMB, decide if they are eligible for SLIB (see WAG 06-13-02) or QI-1 (see WAG 06-14-02).
    2. Deny application through IPACS or AIS, if countable income is more than the QMB, SLIB, and QI-1 limits.
    3. Enter Code 00 in Item 39 of Form 552, to send a centrally generated denial notice, Form 360C.
  9. (FCRC) Approve application through AIS or IPACS if QMB eligibility exists (see WAG 17-02-04 for AIS, or WAG 25-08-02-c for IPACS). Enter additional information on Form 552:

    Item 60 -Enter Social Security/Medicare claim number. Also enter status indicator 9 following Code QMB. Enter eligibility effective date only if QMB eligibility is decided on last workday of month and IPACS is down. For example, QMB eligibility is decided on 03/31/99. IPACS is down and the action cannot be taken until 04/01/99. Enter 041999.

    NOTE: Central office enters effective date in Item 60 in all other cases. 

    Enter information following Code HIB and Code SMIB code, if needed. 

  10. (FCRC) Complete Form 1442 to report health insurance coverage, if needed.

Application for QMB and Cash and/or Medical

  1. (FCRC) Have the applicant complete the Request for Financial Assistance - Medical Assistance - Food Stamps (Form 2378C).
  2. (FCRC) Code Form 552 to cancel QMB Only case.
    1. Use TAR 95. This allows registration of application for other benefits. It also authorizes a 3-month extension of QMB, starting with the effective month of the cancellation action, to decide eligibility for other benefits.
    2. Do not put an entry in Item 77.
  3. (FCRC) Do not send a cancellation notice.
  4. (System) Registers application using same case ID number, unless assigned to a category other than 01, 02, 03, 91, 92, or 93.

Application for QMB and food stamps

  1. (FCRC) Have the applicant complete Form 2378C.
  2. (FCRC) Approve or deny the QMB Only application, as appropriate.
  3. (FCRC) Approve or deny the FS application, as appropriate.

    NOTE: Charges for Medicare cost-sharing (such as Medicare premiums, deductibles, and coinsurance) cannot be allowed as medical deductions for FS purposes for persons in QMB status. 

    1. Approve regular roll benefits on the QMB case, if client is eligible for FS.