Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for  low-income Medicare beneficiaries, qualify enrollees for the   "Extra Help" subsidy for Part D prescription drugs, and -- for those in QMB - pay Medicare coinsurance and deductibles.     As of 2023, there are TWO separate MSP programs: the Qualified Medicare Beneficiary (QMB) Program  and the Qualified Individual (QI) Program.  The  Specified Low Income Medicare Beneficiary (SLMB) Program has been phased out, and everyone who had SLIMB should have qualified for QMB.   

Download the 2024 Fact Sheet on MSP in NYS by Medicare Rights Center  ENGLISH    SPANISH

State law:  N.Y. Soc. Serv. L. § 367-a(3)(a), (b), and (d). 

Income Limits for  MSP's increased in NYS!!  see Table below  

• Timing - See this article for what to do if you now have QI-1 or SLIMB and want to upgrade to QMB with or without Medicaid. 

TOPICS COVERED IN THIS ARTICLE 

1.  No Asset Limit

1A.  Summary Chart of MSP Programs  with current income limits

2.  Income Limits & Rules  and Household Size 

• What if enrolling in QMB causes the consumer to have a spend-down?

3.  The Three MSP Programs (reduced to TWO in 2023) - What are they and how are they Different? 

4.  FOUR Special Benefits of MSP Programs:

1. Back Door to Extra Help with Part D

2. MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period

3. No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP

4. Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 

5.   Enrolling in an MSP - Automatic Enrollment & Applications for People who Have Medicare 

1. WHO IS AUTOMATICALLY ENROLLED IN AN MSP

2. Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP

3. MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income.  

6.   Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 

7.   What Happens After MSP Approved - How Part B Premium is Paid

• May MSP be Retroactive 3 months before Application? 

8   Special Benefit of QMBs - Help with Medicare Cost-Sharing 

9.   Medicare Insurance Premium Payment (MIPP) Program - alternate to MSP in some situations.  See this article for more info.

1.    NO ASSET LIMIT!  

Since April 1, 2008, none of the MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might  not qualify for Medicaid because of excess resources can qualify for an MSP.   

1.A.  SUMMARY CHART OF MSP BENEFITS - 2023  

2.    INCOME LIMITS and RULES

Both of the MSP programs have different income eligibility requirements and provide different benefits.   The income limits are tied to the Federal Poverty Level (FPL). The figures in the above chart are based on  the 2024 FPL, announced by NYS DOH. in February 2024 in the DOH GIS 24 MA/01 - 2024 Federal Poverty Levels and ATTACHMENT.   

See 2024 Fact Sheet on MSP in NYS by Medicare Rights Center  ENGLISH    SPANISH

• Income is determined by the same methodology as is used for determining in eligibility for SSI

The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.  N.Y. Soc. Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7.  Gross income is counted, although there are certain types of income that are disregarded. 

The most common income disregards, also known as deductions, include:

(a)  The first $20 of your & your spouse's monthly income, earned or unearned ($20 per couple max);

(b) SSI EARNED INCOME DISREGARDS:

*  The first $65 of monthly wages of you and your spouse,

*  One-half of the remaining monthly wages (after the $65 is deducted);

*   Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.  For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. 

(c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part  D premium but only to the extent the premium exceeds the Extra Help benchmark amount)

(d) Food stamps not counted.

You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart.

• MSP applicants and recipients age 65 and older who are eligible for, but not receiving Social Security retirement benefits, must apply for Social Security as a condition of receiving MSP.  This stems from Medicaid's requirement to pursue potentially available income.  GIS 13 MA/05
• HOUSEHOLD SIZE: Is Client considered “ONE” or “TWO” for using Income Limits?

As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher.    The above chart shows that Households of TWO have a higher income limit than households of ONE.  The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2.  See DAB Household Size Chart.

Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP.

EXAMPLE:  Bob's Social Security is $1800/month.  He is age 67 and has Medicare.  His wife, Nancy, is age 62 and is not disabled and does not work.  Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit.

2010 NYS DOH change - all married individuals are considered a household of TWO.  DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.  This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program.   Under these rules, Bob is now eligible for an MSP. 

When is One Better than Two?  Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP.  In such cases, "spousal refusal" may be used  SSL 366.3(a).  (Link is to NYC HRA form, can be adapted for other counties).  

• What if enrolling in QMB causes the consumer to have a spend-down?  There are a few options:

  1. Income placed in an SNT or pooled income trust is disregarded not only for Medicaid but also for a Medicare Savings Program. See GIS 19 MA/04 – Clarification of Policy for Treatment of Income Placed in Medicaid Exception Trusts; Fair Hearing No. 4399513P (Nassau Co., Jan. 31, 2006)(available in WNYLC Online Resource Center, Fair Hearing Database, free registration required) 

  2. But what if enrolling in QMB creates a small spend-down -- less than the amount of the Part B premium?   For these people, if they do not enroll in QMB, and the Part B premium is deducted from their inome, it reduces their countable income to below the Medicaid limit.  But if they enroll in QMB, they will have a spend-down.  The consumer should be reimbursed for the  difference between their countable income and the income limit, not necessarily the full amount of the premium. See GIS 02-MA-019: Reimbursement of Health Insurance Premiums.  See more about "MIPP" programs that reimburse consumers for the Part B premium here - in situations where MSP does not help. 

  3. If consumer does not need Medicaid, she can qualify for QI-1. 

3.   The Two  (Formerly Three) Medicare Savings Programs - what are they and how are they different?

1.  Qualified Medicare Beneficiary (QMB).   The QMB program provides the most comprehensive benefits.  2023 --  Income limit increased from 100% to 138% of the Federal Poverty Level (FPL).  The QMB program covers virtually all Medicare cost-sharing obligations:  Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance.  QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

**   See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 

**   See  NYC HRA QMB Recertification form

**     Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center).

2.  Specified Low-Income Medicare Beneficiary (SLIMB).  This program was eliminated in 2023.   All previous SLIMB beneficiaries should have been deemed eligible for QMB, for which the income limit increased to 138% FPL.  Some will also qualify for Medicaid if their assets are within the Medicaid limits, which are also increasing.  Through 2022, SLIMB was for those with incomes between 100% and 120% FPL, and covered Part B premiums only.  TIMING for switching SLIMB's to QMB.  In December 2022, all those in a Medicare Savings Program  who do not also have Medicaid received this notice, which is an attachment to GIS 22 MA/10).   This includes those in QMB, SLIMB, and QI-1.  The notice explains that they may either submit:

1. a Medicaid application with Supplement A to upgrade coverage to Medicaid, if their assets are under the new Medicaid asset limits OR 

2. an MSP application (DOH-4328) if they only want QMB MSP but not full Medicaid.   

3.   Qualified Individual (QI-1).  Through 2024, QI-1 is for those with incomes between 138% - 186% FPL who do not have Medicaid, increased from a 135% FPL limit.   QI-1 program covers Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.   However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027)  So if you apply in January, you get no retroactive coverage. 

Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid with a spend-down. They cannot have both.   It is their choice.  DOH MRG p. 19.  In contrast, one may receive Medicaid and  QMB (or SLIMB through 2022).

In Dec. 2022, QI-1 recipients received the same notice described above for SLIMB group, explaining that they may submit a Medicaid application if their assets are within the Medicaid limits, or submit an MSP application (DOH-4328) to upgrade to QMB. 

4.    Four Special Benefits of MSPs (in addition to NO ASSET TEST): 

Benefit 1.  Back Door to Medicare Part D "Extra Help" or Low Income Subsidy --

All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.  They have no Part D deductible or  doughnut hole, the premium is subsidized, and they pay very low copayments.   Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year.

• The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL.  However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit.  People applying to the Social Security Administration for Extra Help might be rejected for this reason. 

• 2009-10 changes to federal law called "MIPPA"  requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients.   The effective date of the MSP application must be the same date as the Extra Help application.  Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application.  The State implementing procedures are in DOH 2010 ADM-03.    Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010

Benefit 2.   MSPs Automatically Waive Late Enrollment Penalties for Part B

Generally one must  enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability.  An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.  If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP).  Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July.   Enrollment in an MSP automatically eliminates such penalties... for life.. even if one later ceases to be eligible for the MSP.  AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A.  See Medicare Rights Center flyer.

Benefit 3.   No Medicaid Lien on Estate to Recover MSP Benefits Paid 

Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of  Medicaid services that were provided after the recipient reached the age of 55.  Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs.  In 2010, Congress expanded protection for MSP benefits.  Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.  The federal government made this change in order to eliminate barriers to enrollment in MSPs.   See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery   The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses.

Benefit 4.   SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily 

Many people receive both SNAP (Food Stamp) benefits and MSP.    Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium.  Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down.  Here are some protections:

• Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased? And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?

• The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods.

• Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

• See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website.  

5.   Enrolling in an MSP for people who have free Medicare Part A - Automatic enrollment & MSP applications

Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.  The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment.  See 3rd bullet below.  Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP.  See below.

1. WHO IS AUTOMATICALLY ENROLLED IN AN MSP?:

• Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. 

• Clients who are already enrolled in Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility and enrolled in MSP when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).   They do not have to expressly apply for MSP. 

•  If a Medicaid-only recipient becomes eligible for Medicare,  then how they enroll in an MSP depends on whether their Medicaid is managed at the local DSS Medicaid office or on NYSOH.

  • If Medicaid is administered at the local Medicaid office (HRA in NYC) then at the next renewal after they enroll in Medicare, if not earlier,  the Medicaid agency should automatically enroll them in the Qualifed Medicare Beneficiary (QMB) program, if enrollment in QMB does not create or increase a Medicaid spend-down. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). 

    • If enrolling in QMB would create or increase a Medicaid  spenddown, the Medicaid agency should give them the choice of whether or not to receive MSP. (Medicaid Reference Guide (MRG)  p. 19).  Such individuals might be eligible for the QI-1 MSP, which has a higher income limit than QMB, but they are not allowed to have both Medicaid and QI-1.  If they want Medicaid, they would have to enroll in a Pooled Income Trust or, if they are under age 65, an individual Supplemental Needs Trust to qualify for both Medicaid and QMB.  

  • If Medicaid is administered on the NYS of Health  marketplace (NYSOH) and they enroll in Medicare - NYSOH should  enroll them in the MIPP program, which reimbursed their Part B premium but does not give them the full benefit of the QMB program.  This  should be changing under GIS 23 MA/10 - Update to Medicare Premium Payment Process for Individuals Referred From NY State of Health to a Local Department of Social Services May 26, 2023.   GIS 23 MA/10 says NYSOH will enroll in MSP those consumers who NYSOH refers to the local DSS/HRA  to administer their Medicaid, now that they have Medicare and need to transition to non-MAGI Medicaid.  However, during the COVID unwinding and through the present time many new dual eligibles continue to have their Medicaid administered by NYSOH.  (See No. 4 under this link.)  Until NYSOH refers their case to be managed by the local DSS, they will only have MIPP and not full MSP.  

• Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted & enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. 

  • Strategy TIP:  Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.  SSA processes these requests quickly, and it will be routed to the State for MSP processing.  Since MSP applications take a while, at least the filing date will be retroactive.  

  • Note: the above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application.  As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1.

2.   APPLYING FOR MSP DIRECTLY WITH LOCAL MEDICAID OFFICE

   1.  Client already has Medicaid with Local District/HRA but not MSP.   They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them.  (NYS DOH 2000-ADM-7 and GIS 05 MA 033). 

But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled.

• In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program.  Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov.  Use by secure email.  If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021)

2. If do not have Medicaid  -- must apply for an MSP through their local social services district.  (See more in Section D. below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare.

   If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (the DOH-4328 (Rev. 8/2017-- English) (2017 Spanish version not yet available).   Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid.  See 10 ADM-04. 

   Applicants will need to submit proof of income, a copy of their Medicare card (front & back), and proof of residency/address. See the application form for other instructions.

One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too.  One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for QMB instead of QI-1. 

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person.

3. MIPPA -  Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.   The letters are:

6.   Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program"

Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

• See Step-by-Step Guide by the Medicare Rights Center).  This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium.  

• See also GIS 04 MA/013.

• In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare Beneficiaries."  It includes important clarifications, such as:

  •  SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program.

  • Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

  • In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period.   (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 

7.   What happens after the MSP approval - How is Part B premium paid

• For both MSP programs, the Medicaid program is now responsible for paying the Part B premiums,  even though the MSP enrollee is not necessarily a recipient of Medicaid.

• The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS

  • SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient. (Note: this process can take awhile!!!)

  • CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS).

• ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?

  • ​The answer is different for the 2 MSP programs.

  • QMB - No Retroactive Eligibility  – Benefits begin the month after the month of  the MSP application.   18 NYCRR  § 360-7.8(b)(5)

  • QI-1 - YES up to 3 months but only in the same calendar year.  No retroactive eligibility to the previous year.  

8.    QMBs -Special Rules on Cost-Sharing.  QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.  However, there are limitations.  First, co-insurance will only be paid if the provide accepts Medicaid.  Not all Medicare provides accept Medicaid.  Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.  But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance.   Click here for an article that explains all of these rules. 

This article was authored by the Empire Justice Center.