Under mandatory Medicaid eligibility pathways referred to as Medicare Savings Programs (MSPs), dually eligible beneficiaries may qualify for assistance with payment of Medicare premiums and, in some cases, Medicare cost sharing. Individuals who only receive assistance through the MSPs, but do not receive full Medicaid benefits, are referred to as partial-benefit dually eligible beneficiaries. Individuals who qualify for full Medicaid benefits through other pathways, known as full-benefit dually eligible beneficiaries, may also receive assistance through the MSPs. There are four types of MSPs, with the level of assistance varying by income and whether the beneficiary is eligible for full or partial Medicaid benefits (Table 1).
TABLE 1. Medicare Savings Programs as of October 2021
| Type | Full or partial Medicaid benefits | Federal income limit | Federal asset limits | Benefits | |
| Individual | Married couple | ||||
| Qualified Medicare Beneficiary (QMB) | |||||
| QMB only | Partial | 100% FPL or below | $7,970 | $11,960 | Entitled to Medicare Part A, only eligible for Medicaid under MSP, and qualify for Medicaid payment of: •Medicare Part A & Part B premiums •At state option, certain premiums charged by Medicare Advantage plans •Medicare deductibles, coinsurance, and copayments (except nominal copayments in Part D) |
| QMB plus | Full | 100% FPL or below | $2,000 | $3,000 | Entitled to Medicare Part A, eligible for Medicaid under mandatory or optional pathway in addition to MSP, and qualify for Medicaid payment of: •Medicare Part A & Part B premiums •At state option, certain premiums charged by Medicare Advantage plans •Medicare deductibles, coinsurance, and copayments (except nominal copayments in Part D) •All Medicaid covered services |
| Specified Low-Income Medicare Beneficiary (SLMB) | |||||
| SLMB only | Partial | 101%-120% FPL | $7,970 | $11,960 | Entitled to Medicare Part A, only eligible for Medicaid under MSP, and qualify for Medicaid payment of: •Medicare Part B premiums |
| SLMB plus | Full | 101%-120% FPL | $2,000 | $3,000 | Entitled to Medicare Part A, eligible for Medicaid under mandatory or optional pathway in addition to MSP, and qualify for Medicaid payment of: •Medicare Part B premiums •At state option, certain premiums charged by Medicare Advantage plans •Medicare deductibles, coinsurance, and copayments (except nominal copayments in Part D); state may elect to pay only for Medicare services covered by Medicaid •All Medicaid covered services |
| Qualifying Individual (QI) | |||||
| QI | Partial | 121%-135% FPL | $7,970 | $11,960 | Entitled to Medicare Part A, only eligible for Medicaid under MSP, and qualify for Medicaid payment of: •Medicare Part B premiums |
| Qualified Disabled and Working Individuals (QDWI) | |||||
| QDWI | Partial | 200% FPL or below | $4,000 | $6,000 | Lost Medicare Part A benefits because of their return to work but eligible to purchase Medicare Part A, only eligible for Medicaid under MSP, and qualify for Medicaid payment of: •Medicare Part A premiums |
Notes: FPL is federal poverty level. $2,000 and $3,000 are the asset limits for the Supplemental Security Income (SSI) program. Although certain categories of dually eligible beneficiaries are eligible for Medicaid coverage of their Medicare cost sharing, the Balanced Budget Act of 1997 gave states the option of paying the lesser of (1) the full amount of Medicare deductibles and coinsurance, or (2) the amount, if any, by which Medicaid’s rate for a service exceeds the amount already paid by Medicare. Some states, referred to as 209(b) states, use more restrictive limits and methodologies when determining eligibility for full Medicaid benefits. See MACStats Exhibit 37 for eligibility levels in 209(b) states: https://www.macpac.gov/publication/medicaid-income-eligibility-levels-as-a-percentage-of-the-fpl-for-individuals-age-65-and-older-and-people-with-disabilities-by-state/
Sources: Centers for Medicare & Medicaid Services (CMS). 2019. Medicare Savings Programs. https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html#collapse-2614. Social Security Administration (SSA). 2019. Program Operations Manual System (POMS). https://secure.ssa.gov/poms.nsf/lnx/0600815023. Social Security Administration (SSA). 2019. OASDI and SSI program rates & limits, 2019. https://www.ssa.gov/policy/docs/quickfacts/prog_highlights/RatesLimits2019.html.
In calendar year 2013, 8.8 million full and partial-benefit dually eligible beneficiaries received Medicaid assistance under the MSPs. Enrollment was primarily concentrated in the Qualified Medicare Beneficiary (QMB) program with about 7 million individuals enrolled.
MACPAC has found that participation rates are low across all MSPs:
- 53 percent for the Qualified Medicare Beneficiary (QMB) program
- 32 percent for the Specified Low-Income Medicare Beneficiary (SLMB) program
- 15 percent for the Qualifying Individual (QI) program
States are not obligated to pay the full amount of Medicare cost sharing if the provider payment would exceed the state’s Medicaid rate for the same service. States have the option to pay, for a given Medicare service received by a dually eligible beneficiary, the lesser of (1) the full amount of Medicare deductibles and coinsurance or (2) the amount by which Medicaid’s rate for the same service exceeds what Medicare has already paid. MACPAC’s analysis of state policies has documented that more than 30 states are using the lesser of option. For a state-by-state compendium of Medicaid payment policies for Medicare cost sharing, see MACPAC’s State Medicaid Payment Policies for Medicare Cost Sharing.
Medicaid policies for covering Medicare cost sharing have modest but statistically significant effects on access to care. MACPAC’s analysis found that paying a higher percentage of Medicare cost sharing increases dually eligible beneficiaries’ likelihood, relative to that of non-dually eligible Medicare beneficiaries, of using selected Medicare outpatient services and decreases the use of safety net provider services. For more information, see Effects of Medicaid Coverage of Medicare Cost Sharing on Access to Care from our March 2015 report to Congress.
For a recommendation to increase enrollment in the MSPs, see our chapter on Improving Participation in the Medicare Savings Programs in our June 2020 report to Congress. For more information on enrollment in MSPs, see our issue brief Medicare Savings Programs: New Estimates Continue to Show Many Eligible Individuals Not Enrolled. To read the contractor report with a full analysis of enrollment in the MSP programs, see Medicare Savings Program: Enrollees and Eligible Non-Enrollees.
