Most people enroll in Medicare Part B either during their Initial Enrollment Period (IEP) surrounding their 65th birthday or during a Special Enrollment Period (SEP) that entitles them to enroll into Medicare Part B later (for example, people aged 65 and over who are still working and have health coverage through their or their spouse’s employer can generally delay enrolling in Part B). For those who missed their IEP and who do not qualify for a SEP, there is another opportunity to enroll in Medicare Part B each year. This is called the General Enrollment Period (GEP) and lasts from January 1 to March 31each year. Beneficiaries who failed to enroll in Part B when first eligible can use the GEP to enroll in Part B. Coverage will start the first day of the month following enrollment. Note, however, that a Late Enrollment Penalty (LEP) may be added to the Part B premium for anyone who failed to enroll in Part B and did not have other coverage that allowed them to delay Part B enrollment without penalty.
The GEP is important for anyone who missed enrolling in Part B when first eligible, and is also important for individuals who are not eligible for premium-free Medicare Part A. Most people do not pay a premium for Medicare Part A because they have sufficient work history. However, for people who do not have this work history, the Part A premium can cost hundreds of dollars per month (see below).
For low-income beneficiaries who struggle to afford Medicare premiums, a state buy-in may be an option.
Those who were unable to enroll in Medicare due to the cost of the Part A and/or Part B premium may be eligible for a state buy-in. State buy-in programs can allow the state to pay for an eligible beneficiary’s Part B premium, as well as the Part A premium for those who are not entitled to premium-free Part A. The state buy-in will also eliminate any late enrollment penalties that would otherwise be added to the beneficiary’s premiums.
In addition to the important benefits covered under Part A (primarily hospital, skilled nursing facility and some home health and hospice coverage), Part A entitlement triggers eligibility for the Qualified Medicare Beneficiary (QMB) program. QMB helps certain low-income people with health care costs associated with Medicare, including all of Medicare Part A and Part B premiums and cost-sharing and nearly all of Part D premiums and cost-sharing. Without being entitled to Part A first, however, beneficiaries cannot enroll in QMB.
What is QMB?
QMB is one of the Medicare Savings Programs, which provide assistance with out-of-pocket Medicare costs for low-income beneficiaries, including premiums, deductibles and co-insurance for Medicare-covered services.
Eligibility
Under the QMB program, state Medicaid programs pay the Medicare premiums, deductibles and co-insurance for beneficiaries with income and assets below a certain threshold. The eligibility for QMB varies by state. The 2025 federal income and asset limits for QMB are:
- Countable incomes below 100% of Federal Poverty Levels (FPL);
- Countable resources below $9,660 for an individual and $14,470 for a couple.
Note that some states use higher income limits than these federal limits, and some states do not consider assets for QMB eligibility. For example, Connecticut’s QMB eligibility threshold is 211% of the FPL, and resources are not considered. In addition, not all types and amounts of income are counted in full in all states.
Benefits
QMB benefits include payment of Part A and B premiums, as well as 100% coverage of deductibles, coinsurance and copayments for all Medicare-covered services. QMB and other levels of the Medicare Savings Program also automatically qualifies and enrolls beneficiaries in the Low-Income Subsidy, also called Extra Help, which significantly reduces beneficiaries’ Part D cost-sharing responsibility.
Connection to Medicare Part A
Eligibility for the QMB program is dependent upon an individual’s entitlement to Medicare Part A. Most Medicare beneficiaries receive Part A benefits without payment of a premium because of their employment history. People age 65 and over who are not entitled to premium-free Part A but who elect to purchase Part B coverage (or for whom Part B premiums are paid by the State Medicaid program) may also purchase Part A, but it is very expensive – ranging from $285-$518 per month in 2025.
Part A Buy-In States vs. Group Payer States
States are authorized by the Social Security Act to enter into formal “Buy-In” agreements with CMS to pay Medicare premiums for low-income beneficiaries. One benefit of having a Part A buy-in agreement is that individuals can be enrolled in Part A (and subsequently in the QMB program) at any time during the year. All states have Part B buy-in agreements, and most states have Part A buy-in agreements; they are called Part A Buy-In States. (Note: as of January 1, 2025, California is now a Part A Buy-in State.)
The following states do not have Part A buy-in agreements: Alabama, Arizona, Colorado, Illinois, Kansas, Kentucky, Missouri, Nebraska, New Jersey, New Mexico, South Carolina, Utah and Virginia. These states are called Group Payer States, and only allow beneficiaries to apply for premium-Part A during the General Enrollment Period. Individuals in group payer state face greater barriers to participation in the QMB program than individuals in Part A Buy-In States.
Again, individuals in Group Payer States who did not enroll in Part A when they were first eligible to do so can only enroll in Part A during the General Enrollment Period described above. This period ends March 31st each year. Individuals who do not enroll in Part A by March 31 will have to wait until January of the following year to do so.
Procedure for Purchasing Part A
Typically, after their Initial Enrollment Period, individuals are entitled to enroll in Part A or Part B only during the Medicare General Enrollment Period that runs from January 1 through March 31 of each year, unless they qualify for a Special Enrollment Period. Eligibility for Part A and B coverage begins the 1st of the month following the month of enrollment for those enrolling during the General Enrollment Period. Except in special circumstances, Medicare assesses a 10% penalty on the monthly premium for enrollment after the Initial Enrollment Period. The Part A enrollment penalty does not last indefinitely. For people enrolled in QMB, the state pays the penalty for late enrollment.
Conditional Part A Application Process for Potential QMB Participants
Usually, enrollment in QMB happens after a beneficiary already has Part A and B. A “conditional enrollment” process has been created to address the dilemma of people who wish to enroll in Part A and to participate in QMB, but who cannot afford to pay the Part A premium while waiting for QMB to start to pay the Part A premium. A conditional enrollment is when a beneficiary requests to enroll in Part A on the condition that the state will pay the Part A premium. If the state does not subsequently find the beneficiary eligible for QMB and pay their premium, the Part A application is dropped, and the beneficiary does not have any financial liability for Part A.
Note that beneficiaries must also apply for Part B when they apply for conditional Part A. There is no “conditional” Part B – it is considered a regular Part B application. Due to the rules surrounding the start dates for buy-in eligibility groups, QMB beneficiaries may be responsible for at least one month of the Part B premium, even if they apply for QMB immediately after their enrollment in Part B and conditional enrollment in Part A. They will not be responsible for any Part A premiums.
The conditional enrollment process described above also applies in Part A Buy-In States, but the process can be used at any time, not just during the General Enrollment period.
Details on the buy-in process as well as updates on MSP eligibility and enrollment processes are in chapter one of the Manual for the State Payment of Medicare Premiums (formerly called the “State Buy-in Manual”).
Information on Social Security’s role in conditional enrollment is available through the SSA Program Operations Manual System (POMS) at http://policy.ssa.gov/poms.nsf/lnx/0600801140
If unable to get a clear answer from Social Security, one might pursue conditional enrollment as follows:
- Secure a Form 795 from the Social Security Administration (SSA) (available online at www.ssa.gov/online/ssa-795.pdf)
- Type or write into the large blank (lined) space the following: “I wish to enroll for Hospital Insurance under Medicare on a monthly premium basis, which is in addition to my current coverage for Medical Insurance (or “I also wish to apply for Medical Insurance” if the client does not have Part B). I understand that the State will pay my premium based on my eligibility for Medicaid (Medical Assistance) as a Qualified Medicare Beneficiary. I also understand that if I am terminated under Medicaid (Medical Assistance) as a Qualified Medicare Beneficiary, I will have to pay my premium if I want to keep my Medicare Part A Insurance.”
- Submit the form to SSA with a completed application for Part A
- Go to the Medicaid office to apply for QMB with a copy of the Part A application and SSA Form 795
Beneficiaries who believe they have been given erroneous information by SSA concerning Medicare Part A, such as not being told of the possibility of conditional enrollment, may be able to have their enrollment date moved back by seeking equitable relief from the agency. See section HI 00830.005 of the SSA Program Operations Manual System (POMS) for more detail.
Consequences of Failure to Enroll in Part A: Help with Part D
The possible consequences of not obtaining Medicare Part A coverage increased in 2006 with the advent of Medicare Part D. As noted earlier, QMB status entitles the beneficiary to automatic qualification for the Medicare Part D full Low-Income Subsidy (LIS, also known as “Extra Help”) to help pay for prescription drugs. This significant subsidy entitles the beneficiary to minimal co-payments, no premium or deductible and no coverage gap. In addition, under the Part D program, coverage is not available for drugs covered by Parts A or B, even if the particular beneficiary needing such drugs does not have Parts A or B. (Note that QMB is not the only path to the Part D Low-Income Subsidy; anyone can apply directly to the Social Security Administration for that assistance.)
Conclusion
The processes described in this Alert are not necessarily easy to use. Advocates from both Group Payer States and Part A Buy-In States report difficulties in finding state and SSA personnel who are familiar with conditional enrollment. Individuals, too, may be skeptical of taking this action, especially if agency personnel cannot reassure them they will not be billed for the Part A premium. In addition, individuals without Part B must also enroll in Part B to enroll in Part A. There is no conditional enrollment for Part B, so the individual may be concerned about having to pay Part B premiums, even though the QMB benefit will cover those once it is in place. Because the individual must enroll in Part B before enrolling in QMB, beneficiaries typically are responsible for at least one month of Part B premium, and this can be a hardship.
The Center for Medicare Advocacy is interested in the myriad challenges of QMB enrollment and would appreciate hearing from advocates about their experiences with SSA and their state Medicaid agencies relating to these issues.
February 6, 2025 – M. Lambert