Effective Dates: 12/31/2024 - Present

Identification Number:
EM-24068
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/OCO-CSTs/ OHO
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Changes to the Qualified Medicare Beneficiary (QMB) Eligibility Group in the State of California
Type:EM - Emergency Messages
Program:Medicare; Medicaid
Link To Reference:See References at the end of this AM.
 

Retention Date: 12/31/2025

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 their impact on SSA processes on or after 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.

A state can enroll an individual in QMB coverage if the individual meets their state’s financial eligibility guidelines and the individual:


    · Has premium-free Part A or premium Part A; or

    · Has part B only and either:

        o Resides in a Part A buy-in state; or

        o Resides in a group payer state and has enrolled in conditional Part A at SSA during a Medicare enrollment period

See HI 00801.140 for instructions on premium Part A enrollments for QMBs.

Effective January 1, 2025, CA will convert from a group payer state to a Part A buy-in state.

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). As in all states, SSA initiates 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 HI 00815.030E, Auto-accrete States, Category 1.

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 modifies its QMB enrollment processes for full-scope Medi-Cal recipients who are uninsured for Part A. 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 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. Further, as a Part A buy-in state, CA will automatically enroll into the QMB group full-scope Medi-Cal recipients who have supplemental security income (SSI)/federally administered state supplement program (SSP) and Part B only, instead of requiring them to file a separate QMB application with the state.

Consult the table below for a summary of CA’s QMB changes and beneficiary notices and for the accompanying changes in SSA processes on or after January 1, 2025.

CA Policy Change CA beneficiary NoticeImpact on SSA Processes
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:


    · SSI/SSP benefits,

    · Full-scope Medi-Cal; and

    · Part B only

Removes the need for conditional Part A enrollment at SSA to obtain QMB coverage.

    · SSA initiates Part B buy-in for SSI Medi-Cal recipients. See HI 00815.030B and E.


    · Because CA is a Part A buy-in state, the state will 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 conditional Part A during a Medicare enrollment period. See HI 00801.140E.3
Full-scope Medi-Cal recipients who do not have SSI (non-SSI) and are uninsured for Part A

County offices can enroll non-SSI Medi-Cal recipients into the QMB group once they are enrolled in Part B.


    · If the non-SSI Medi-Cal recipient does not have Medicare, the state will continue to advise them to enroll in Medicare at SSA.

N/A Removes the need for non-SSI full-scope Medi-Cal recipients who already have Part B to enroll in conditional Part A at SSA to obtain QMB coverage.

    · Because CA is a Part A buy-in state, the county offices will enroll individuals in the QMB group and Part A buy-in once they are enrolled in Part B. Part A conditional enrollment is no longer required. See HI 00801.140E.3

Removes the need for non-SSI full-scope Medi-Cal recipients who are applying for Part B to file for conditional Part A to obtain QMB coverage.

    · SSA will continue to initiate Part B buy-in through the PW accretion process as described in HI 00815.030D and E.


    · Because CA is a Part A buy-in state, the county office will enroll the individual in the QMB group and Part A buy-in once the individual is enrolled in Part B. Part A conditional enrollment 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 DHCS offices. It had no impact on SSA processes. Subsequently, it became a Part A buy-in state effective January 1, 2025, and began auto-enrolling into the QMB group eligible 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


EM-24068 - Changes to the Qualified Medicare Beneficiary (QMB) Eligibility Group in the State of California - 12/31/2024