Home ►
Billing news ►
Prohibition on billing dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) program
Last Modified: 9/4/2024
Location: FL, PR, USVI
Business: Part A, Part B
QMB is a Medicare savings program that exempts Medicare beneficiaries from Medicare cost-sharing liability. It is a state Medicaid benefit that covers Medicare premiums and deductibles, coinsurance, and copayments, subject to state payment limits.
State Medicaid programs may pay providers for Medicare deductibles, coinsurance, and copayments. However, as permitted by federal law, states can limit provider reimbursement for Medicare cost-sharing under certain circumstances.
You must accept the payments by Medicare and Medicaid (if any) as payment in full for services rendered to a QMB beneficiary.
You may not bill QMB individuals for Medicare cost-sharing, regardless of whether the state reimburses providers for the full Medicare cost-sharing amounts.
Those who inappropriately bill individuals enrolled in QMB are subject to sanctions.
All original Medicare and Medicare Advantage (MA) providers and suppliers, not only those that accept Medicaid, must not charge individuals enrolled in the QMB program for Medicare cost-sharing.
• QMB individuals retain their protection from billing when they cross state lines to receive care.
• You cannot charge QMB individuals, even if the patient’s QMB benefit is provided by a different state than the state in which care is rendered.
• Those enrolled in QMB cannot elect to pay Medicare deductibles, coinsurance, and copays, but may have a small Medicaid copay.
1. Establish processes to routinely identify the QMB status of your Medicare patients prior to billing for items and services.
• Providers and suppliers can use Medicare eligibility data provided to Medicare providers, suppliers, and their authorized billing agents (including clearinghouses and third-party vendors) by CMS’ HIPAA Eligibility Transaction System (HETS) to verify a patient’s QMB status and exemption from cost-sharing charges. For more information, visit the
HETS 
website. You can also find QMB eligibility through
SPOT.
• In July 2018, CMS reintroduced QMB information in the Medicare remittance advice (RA) that original Medicare providers and suppliers can use to identify the QMB status of beneficiaries.
• MA providers and suppliers should also contact the MA plan to learn the best way to identify the QMB status of plan members both before and after claims submission.
• Providers and suppliers may also verify beneficiaries’ QMB status through automated Medicaid eligibility-verification systems in the state in which the person is a resident or by asking beneficiaries for other proof, such as their Medicaid identification card, Medicare Summary Notice (MSN) or other documentation of their QMB status.
2. Ensure that billing procedures and third-party vendors exempt individuals enrolled in the QMB program from Medicare charges and that you remedy billing problems should they occur.
If you have erroneously billed individuals enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.
Determine the billing processes that apply to seeking reimbursement for Medicare cost-sharing from the states in which you operate. Different processes may apply to original Medicare and MA services provided to QMB beneficiaries.
• If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare RA.
• States require all providers, including Medicare providers, to enroll in their Medicaid system for provider claims review, processing, and issuance of the Medicaid RA. Providers should contact the state Medicaid Agency for additional information regarding Medicaid provider enrollment.
Reference
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
