Retention Date: 12/31/2025
Summary of Changes:
This EM replaces the prior version issued on 12/31/2024 and provides updated information and instructions for Changes to the QMB Eligibility Group in the State of California.
Revisions as of 02/28/2025:
Section A: Revised the purpose for the EM to offer clarifications.
Section B: Revised to offer additional clarifications.
Section C: Revised the chart to offer additional clarifications as to when to refer beneficiaries to county Medi-Cal offices and to clarify the actions for SSA.
A. Purpose
This emergency message (EM) provides information to frontline technicians about changes to enrollment policies for the Qualified Medicare Beneficiary (QMB) eligibility group in the state of California (CA) and the correct process for enrollment of individuals into the QMB group, effective since January 1, 2025.
B. Background
The QMB group is a Medicaid eligibility group through which states cover Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums and cost-sharing for low-income Medicare beneficiaries. See HI 00801.139.
Effective January 1, 2025, CA converted from a group payer state to a Part A buy-in state. Becoming a Part A buy-in state enables the California Department of Health Care Services (DHCS) and its county offices to approve QMB coverage for full-scope Medi-Cal recipients who are enrolled in Part B only, eliminating the requirement to enroll in conditional Part A at SSA during a Medicare enrollment period.
A state can enroll an individual in QMB coverage if the individual meets their state’s financial eligibility guidelines and the individual:
For instructions on premium Part A enrollments for QMBs, see HI 00801.140.
Note that in CA, individuals who meet the financial eligibility criteria for the QMB group also qualify for full-benefit Medicaid coverage (full-scope Medi-Cal). SSA can initiate Part B buy-in for full-scope Medi-Cal beneficiaries through the Public Welfare (PW) accretion process. California is an auto-accrete state that includes all Medi-Cal groups in its Part B buy-in agreement. For PW accretion instructions for CA, see Auto-accrete States, Category 1, HI 00815.030E.
C. California’s QMB Enrollment Processes for Full-Scope Medi-Cal Recipients who are Uninsured for Part A
California’s conversion to a Part A buy-in state on January 1, 2025, modified its QMB enrollment processes for full-scope Medi-Cal recipients who are uninsured for Part A. These individuals still must apply for QMB coverage at their county Medi-Cal office unless they are SSI/SSP recipients (in which case DHCS automatically enrolls them in the QMB group).
Because SSI recipients with full-scope Medi-Cal and Part B automatically receive QMB coverage, SSA should not refer them to their county Medi-Cal office to file a QMB application.
Consult the table below for a summary of CA’s QMB changes and beneficiary notices and for the accompanying changes in SSA processes that went into effect January 1, 2025.
| CA Policy Change
What the State can do: | CA Beneficiary Notice | Impact on SSA Processes
What does SSA do now? |
| Full-scope Medi-Cal recipients who have SSI/SSP and are uninsured for Part A*
State will auto-enroll into the QMB eligibility group individuals who have:
|  | Do not establish conditional Part A entitlement; AND
Do not refer the individual to their county Medi-Cal office to apply for QMB coverage.
· If the individual does not have Part B, use the PW accretion process to establish Part B through Part B buy-in. See HI 00815.030 C and E.
· CA will automatically enroll the individual in the QMB group and Part A buy-in once the individual is enrolled in Part B buy-in, without the need for the individual to file conditional Part A at SSA or apply for QMB coverage through their county Medi-Cal office. See HI 00801.140E.3 |
Full-scope Medi-Cal recipients who do not have SSI (non-SSI) and are uninsured for Part A
· County Medi-Cal offices can approve a QMB application for a non-SSI Medi-Cal recipient who is enrolled in Part B only.
· If the non-SSI Medi-Cal recipient does not have Medicare, the county office will continue to advise them to enroll in Medicare at SSA.
| N/A | Do not establish conditional Part A entitlement for non-SSI full-scope Medi-Cal recipients who are uninsured for Part A.
· If the individual does not have Part B, use the PW accretion process to establish Part B through Part B buy-in. See HI 00815.030 D and E.
· If the individual has Part B (whether they are newly enrolled or already had Part B), refer them to their county Medi-Cal office to apply for QMB coverage. If the individual meets California’s financial eligibility criteria for the QMB group, the county Medi-Cal office will enroll them in the QMB group and Part A buy-in. Conditional Part A entitlement is no longer required. See HI 00801.140E.3
|
* Note that effective October 1, 2024, DHCS began auto-enrolling into the QMB group Medi-Cal recipients who have SSI/SSP and premium-free Part A. This change eliminated the need for such individuals to file a separate application for QMB coverage through county Medi-Cal offices. It had no impact on SSA processes. Subsequently, CA became a Part A buy-in state effective January 1, 2025, and began auto-enrolling into the QMB group full-scope Medi-Cal recipients who have SSI/SSP and Part B, regardless of whether or not they also have Part A.
References:
HI 00801.139 Qualified Medicare Beneficiary (QMB) Provisions
HI 00801.140 Premium-Part A Enrollments for Qualified Medicare Beneficiaries (QMBs) – Part A Buy-In States and Group Payer States
HI 00815.030 Establishing State Buy-in for Medicare Part B through The Public Welfare Accretion Process
SM 00850.700 Conditional Enrollments for Premium HI-Qualified Medicare Beneficiaries (QMB)
SM 03040.000 System Processing Instructions
SM 03040.025 Uninsured Medicare and Qualified Medicare Beneficiary (QMB)
SM 03040.230 Qualified Medicare Beneficiary (QMB) Premium HI Third Party