Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program

by  Wyn Staheli, Director of Content - innoviHealth
Oct 7th, 2020

To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program, which is a Medicaid benefit that pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost-sharing to Medicare beneficiaries who are enrolled in QMB, which is something too many organizations are doing. To address this problem, a MedLearn article was released (SE1128) to help advise providers and suppliers regarding this issue. 

If you bill Medicare as either a participating or non-participating provider, you MUST identify these individuals and have policies and procedures in place to avoid incorrectly billing them. Before dismissing this as inapplicable to your organization, it should be noted that, as of 2017, more than one out of eight Medicare beneficiaries were enrolled in this program, so chances are that your organization has treated a QMB enrollee. According to CMS, “Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.” If you have incorrectly billed these individuals, you MUST refund charges (including collection fees) to the patient.

For Original Medicare, most states automatically submit the claim to Medicaid after it has been processed on their end. However, Medicare Advantage (MA) plans might not, so be sure to carefully review your Remittance Advice notices for information (e.g., remark codes) that might indicate that the claim has been submitted to Medicaid.

Note: You must accept assignment when billing Part B covered services.

Alert: Since these payment amounts come from Medicaid, you must be enrolled as a Medicaid provider. Contact your state Medicaid agency for additional information.

The following references contain links to important information from CMS, including an FAQ about identifying these individuals and understanding the rules.

References

• Prohibition Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program MLN Matters SE 1128
• Qualified Medicare Beneficiary Program – FAQ on Billing Requirements 
• Dually Eligible Beneficiaries Under Medicare and Medicaid 
• Qualified Medicare Beneficiary (QMB) Program