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Qualified Medicare Beneficiaries (QMB) Program

The Qualified Medicare Beneficiary (QMB) program, administered by DC Medicaid, provides secondary insurance coverage to Medicare beneficiaries who live in the District with income below $3,418 per month (single) or $4,598 per month (couple). It could cover all your Medicare cost-sharing charges, including premiums, deductibles, and coinsurance. 

What will I save in Medicare premiums? 

The QMB program pays your monthly Medicare premiums. For most people, Medicare Part A does not have a premium. If you do have a Part A premium, the QMB program would cover it. Part B Premiums – you will be paying $170.10. Once you are approved for QMB, Medicaid will cover the full premium amount. If the Social Security Administration deducts your Part B premium from your Social Security check, your monthly benefit should increase by your premium amount after being approved for QMB. If you do not see an increase within two months of receiving a QMB approval letter, please contact us. 

How much will I save in Medicare cost-sharing charges? 

The QMB program provides full supplementary insurance by covering all of Medicare’s cost-sharing amounts. 

• Original Medicare: QMB covers inpatient hospital deductibles of $1,556 and daily inpatient hospital and skilled nursing facility coinsurance charges. It covers the annual Part B deductible of $233 and all coinsurance charges (usually 20% of Medicare’s approved amount) for doctor visits, outpatient hospital services, and medical equipment.

• Medicare Advantage: QMB covers your deductible and copayments for inpatient hospital stays, outpatient hospital services, doctor visits, and medical equipment.

What happens to my Part D prescription drug plan?

People in QMB automatically qualify for Extra Help, a Medicare program that helps pay for your Part D prescription drug plan. Extra Help could cover your premium, deductible, and reduce your prescription copays to no more than $3.95 for generic and $9.85 for brand name prescription medications.

How does the law protect me? 

Federal Medicare law says that QMBs have no legal liability to pay any provider or Medicare Advantage (MA) plan for cost-sharing. In other words, when Medicare pays something, you pay nothing. If providers bill you for Medicare cost-sharing, they may owe you a refund. 

How is the QMB program different from Medicaid? 

Medicaid, also known as Medical Assistance or QMB Plus, provides benefits for services not normally covered by Medicare. QMB, which is partial Medicaid, helps pay for services only if they are covered by Medicare. For example, QMB does not pay for dental or routine vision services because these services are not generally covered by Medicare. If you are uncertain which program you are enrolled in, please contact our office at 202-724-5626.

Inform your providers. 

Always show both your Medicare and QMB cards at the doctor. If you have been approved for QMB and need a card, contact the Health Care Ombudsman’s office at 877-685-6391. 

Problems or questions? Call us! 

When health care providers are not familiar with the QMB program, billing problems may occur. If any provider bills you for Medicare deductibles or copayments, get in touch with our office right away. We will work with the provider and you to resolve the problem. 

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