Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 3

See the First and second part for better understanding.

Qualifying Individual (QI)

A QI is an individual who:
 ■ is entitled to Part A;
 ■ has income that is at least 120 percent of the
 ■ FPL, but less than 135 percent of the FPL;
 ■ has resources that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for any QI are 100 percent federally funded and the total expenditures are limited by statute.


Full Benefit Dual Eligible (FBDE)

An FBDE is an individual who:

 ■ is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized or home
and community-based waivers; and
 ■ does not meet the income or resource criteria for a QMB or an SLMB.


Qualified  Disabled and Working Individual (QDWI)

A QDWI is an individual who:

 ■ lost Medicare Part A benefits due to returning to work, but is eligible to enroll in and purchase Medicare Part A;
 ■ does not have an income that exceeds 200 percent of the FPL;
 ■ has resource that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation; and
 ■ may not be otherwise eligible for Medicaid.

A QDWI is only eligible for Medicaid payment of Part A premiums.


Balance Billing a QMB

For a QMB, Medicaid is responsible for deductible, coinsurance, and copayment amounts for Medicare Part A and Part B covered services. Providers may not bill a QMB for either the balance of the Medicare rate or the provider’s customary charges for Part A or Part B services. The QMB is protected from liability for Part A and Part B charges, even when the amounts the provider receives from Medicare and Medicaid are less than the Medicare rate or less than the provider’s customary charges, as specified in the Balanced Budget Act of 1997 (BBA). Providers who bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing) are subject to sanctions. Providers may not accept QMB patients as “private pay” in order to bill the patient directly, and providers must accept Medicare assignment for all Medicaid patients, including QMBs.


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