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).
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.
NOTE: Initiate SOLQ if client asks for help with verification of Part A.
NOTE: Use the one person standard for clients who have been living in a long term care facility for at least one month.
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.
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.
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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