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Health Line
19-05-2025
- Health
- Health Line
What Is the Qualified Medicare Beneficiary (QMB) Program?
The Qualified Medicare Beneficiary (QMB) program helps those with limited income and resources pay for costs associated with Medicare parts A and B (Original Medicare). Medicare savings programs (MSPs) help people with limited income and resources pay for the costs of Medicare. There are four different MSPs available. The Qualified Medicare Beneficiary (QMB) program is one of them. To enroll in the QMB program, you must be eligible for Medicare Part A and meet certain income and resource limits. You can contact your state's Medicaid office to get specific information on your eligibility and the application process. The QMB program can help pay for Medicare costs including premiums, deductibles, coinsurance, and copays. Continue reading to explore the QMB program, who's eligible, and how you can enroll. How does QMB work with Medicare? The QMB program helps you pay for Medicare costs if you have lower income and resources. It's estimated that more than 1 in 8 Medicare beneficiaries were enrolled in the QMB program in 2023. Specifically, the program pays for: your Medicare Part A deductible your Medicare Part B deductible and monthly premiums other coinsurance and copayment costs associated with Medicare Part A and Part B coverage Extra Help If you qualify for the QMB program, you'll also qualify for Extra Help. This is a program that helps pay for the costs associated with a Medicare Part D prescription drug plans. Extra Help covers things like: monthly premiums deductibles copayments for prescriptions Some pharmacies may still charge a small copay for prescriptions covered under Part D. For 2025, the copayment will be no more than $4.90 for a covered generic drug and $12.15 for a covered brand-name drug. Extra Help only applies to Medicare Part D. It doesn't cover premiums and costs associated with Medicare Advantage (Part C) or Medigap (Medicare supplement insurance) plans. Additional tips for coverage If you're enrolled in the QMB program, the following tips will help ensure that your healthcare costs are covered: Let a healthcare professional know that you're enrolled in the QMB program. Show your Medicare and Medicaid cards or QMB program card any time you seek care. If you receive a bill that should be covered by the QMB program, contact the healthcare professional. Let them know that you're in the QMB program and cannot be billed for things like deductibles, coinsurance, and copays. If the healthcare professional continues to bill you, contact Medicare directly at 800-MEDICARE. They can help confirm with your healthcare professional that you're in the QMB program and refund any payments you've already made. QMB eligibility There are three different eligibility criteria for the QMB program. These include Medicare Part A eligibility, income limits, and resource limits. You can receive QMB benefits whether you have Original Medicare (parts A and B) or a Medicare Advantage plan. MSPs, including the QMB program, are administered through your state's Medicaid program. That means your state will determine whether or not you qualify. For example, different states may have different ways to calculate your income and resources. Let's examine each of the QMB program eligibility criteria in more detail below. Medicare Part A eligibility To enroll in the QMB program, you also need to be eligible for Medicare Part A. Generally, to be eligible for Part A you must be: 65 years or older any age and have a qualifying disability any age and have end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) Income limits If you would like to enroll in the QMB program, you must meet certain monthly income limits. These limits depend on whether you're married or not. For 2025, the monthly income limits for the QMB program are: Individual: $1,325 per month Married couple: $1,783 per month Monthly income limits are higher in Alaska and Hawaii: Alaska: Individual: $1,650 Married couple: $2,223 Hawaii: Individual: $1,520 Married couple: $2,047 Because of this, people living in these states may still be eligible for the QMB program, even if their monthly incomes are higher. The monthly income limit for the QMB program increases each year. That means you should still apply for the program, even if your income goes up slightly. Resource limits In addition to a monthly income limit, there is also a resource limit for the QMB program. Items that count toward this limit include: money you have in checking and savings accounts stocks bonds Some resources, such as your house, car, and furniture, don't count toward the resource limit. Like income limits, the resource limits for the QMB program are different depending on whether or not you're married. For 2025, the resource limits for the QMB program are: Individual: $9,660 Married couple: $14,470 Resource limits also increase every year. As with income limits, you should still apply for the QMB program if your resources have slightly increased. How do I enroll? To see if you qualify and to get information on the application process, contact your state's Medicaid office. Your State Health Insurance Assistance Program (SHIP) may also be able to help if you have additional questions or concerns. The enrollment process requires you to fill out a short application form. The Social Security Administration (SSA) has a model form that can be found here. However, the form that you'll actually fill out may be slightly different, depending on your state. You may be asked to provide additional documentation as a part of your application process. This may include things like: pay stubs bank statements income tax return information If you're enrolled in the QMB program, you'll have to reapply for it each year. This is because your income and resources may change from one year to the next. Your state's Medicaid office can give you information about when and how to reapply. Applying for Extra Help If you qualify for the QMB program, you automatically qualify for Extra Help. You can enroll in the Extra Help program on the SSA website. Once you're enrolled in Extra Help, the SSA will review your income and resource status each year, typically at the end of August. Based on this review, your Extra Help benefits for the upcoming year may stay the same, be adjusted, or be terminated. The takeaway The QMB program is one of four MSPs. These programs help people with limited income and resources pay their Medicare out-of-pocket costs. These covered costs include premiums, deductibles, coinsurance, and copays associated with Medicare parts A and B. If you qualify for the QMB program, you'll also qualify for Extra Help. The QMB program has several different eligibility requirements. You must be eligible for Medicare Part A and meet specified income and resource limits.
Boston Globe
13-05-2025
- Health
- Boston Globe
He needed his medication for multiple sclerosis. He got more paperwork instead.
In 2022, Blum's neurologist recommended he switch his primary MS medication to Kesimpta, which he takes by monthly self-injection. At the time, Blum was on medication that was administered by infusion twice a year in his doctor's office and fully covered by Medicare. Kesimpta, by contrast, would cost many thousands of dollars a year, way too expensive for Blum. (The switch was recommended mainly as a matter of convenience.) That's when Blum discovered he was income-qualified for a no-cost supply of Kesimpta from the Advertisement NPAF said Blum would get his medication at no cost so long as there was no significant change in his finances, Blum said. Advertisement It was a godsend. For the next two and a half years, everything went smoothly. Blum would call NPAF to order his medication and it would arrive at his house in time for his monthly doses. This is what Blum says happened next: In January, when he tried to call in his order as usual, NPAF told him he had to reapply for enrollment. It annoyed him that he had received no advance warning of this new requirement, and it came only a couple of days before his next scheduled dose. But he did as instructed by getting a note from his doctor, filling out a form, and returning both to NPAF, along with a copy of his 2023 tax return, all within 48 hours. (Patient assistance programs overall are tightening rules in response to scrutiny from regulators and the high cost of the programs.) NPAF also required him to obtain documentation that he was not eligible for drug assistance from an alternative program — the Social Security Administration's Nevertheless, he applied online for Extra Help to satisfy NPAF's requirements. The denial letter, however, would take up to 30 days to arrive in the mail, according to the SSA website. Under these circumstances, NPAF provided Blum with his medication even without the denial letter, as a 'courtesy.' A month later, when he tried to refill his medication, NPAF said it hadn't received the Extra Help denial letter. Blum said he was still waiting for it. NPAF agreed to a second 'courtesy' dose of his medication. Advertisement A short time later, the Extra Help letter finally came and Blum forwarded it to NPAF. But in March, NPAF again denied Blum his medication. It said the Extra Help denial letter it received from Blum wasn't what it needed, though it didn't explain why. Blum told NPAF that the SSA website contained a statement about eligibility that clearly excluded him. At NPAF's suggestion, he provided screenshots of the eligibility section of the online application for Extra Help. That apparently was good enough for NPAF. Blum got his medication for March. A month later, when Blum sought a refill, NPAF insisted on a formal denial letter, not screenshots. And this time, NPAF said it would not give him a courtesy refill, leaving Blum confused and demoralized. In an email requesting my help, Blum said NPAF's rejection of the screenshots 'contradicted their previous directive' and came only days before he was supposed to take his next dose. Blum said NPAF should have reached out to him as soon as it determined the screenshots were unacceptable, but instead it waited until he attempted to make a new order. 'Now they are refusing any further help,' he wrote to me. The only way for Blum to receive his medication was to obtain an Extra Help denial letter. But he knew the process for applying, waiting for the letter, then forwarding it to NPAF would be time-consuming (if the letter was accepted at all), likely forcing him to miss at least one monthly dose and maybe more. Advertisement Blum also worried that recent staff cuts at Social Security could add new delays to getting his requested documentation. Blum said he didn't expect an immediate deterioration in his health due to one or two missed doses, but it certainly wouldn't help. The resolution : I wrote to NPAF: 'It seems to me Mr. Blum has done everything in his power to comply with NPAF's requirements, but the requirements' seem to have constantly changed. 'Mr. Blum needs his medication,' I wrote. NPAF reacted quickly by promptly delivering Blum his medication and assuring him he would continue to get it at least until it's time to reapply for enrollment next year. Blum said he was relieved and grateful, though he's a bit wary of what might unfold next year. The takeaway : NPAF, in a statement to me, declined to comment specifically on Blum. But it did say that NPAF patients were informed of the new enrollment process and requirements in 'multiple letters sent out in October-December 2024.' Blum said he received no such letters. Could he have missed them in the mail? 'Highly unlikely,' he said. 'I'm extremely attentive to anything having to do with my health and medication.' In any case, the requirements kept changing. And life is tough enough without these added headaches. What can a consumer learn from Blum's unfortunate experience? Beware that something can always go wrong when it comes to medications and paperwork. Even when things are going smoothly, ask questions and seek assurances, preferably in writing. Anticipate problems, be proactive, document everything — and be persistent. Got a problem? Send your consumer issue to
