Qualified Medicare Beneficiary (QMB) Program

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Qualified Medicare Beneficiaries (QMBs) are dual-eligible beneficiaries with low income (at or below $12,000); they are individuals who have Medicare and are also enrolled with Medicaid, and get help with their Medicare premiums and cost-sharing. Medicare providers may not charge QMBs for Medicare cost-sharing for any Part A and B covered items and services. This applies to all original Medicare and Medicare Advantage providers and suppliers. The providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. Most states do limit their payments of Medicare deductibles, co-insurance, and co-pays for QMBs. Nevertheless, QMBs have no legal liability to pay Medicare/Medicare Advantage providers their cost-sharing amounts. Therefore, all original and Medicare Advantage providers, even those who don’t accept Medicaid, are not allowed to balance bill QMBs.

Due to the lack of understanding of the billing rules, some providers are improperly billing QMBs and sending them to collection agencies when payments are not received. Many QMBs also do not understand and will pay the improper charges. In fact, QMBs cannot waive their QMB status and pay Medicare cost-sharing. As a Medicare/Medicare Advantage provider, you are mandated to follow these balance billing prohibitions.

CMS recommends that providers follow these steps to promote compliance:
1. Establish processes to routinely identify the QMB status of your patients prior to billing.
2. Ensure that billing procedures and third-party vendors exempt QMBs from Medicare charges and remedy billing errors should they occur.
3. Determine your State’s processes to seek Medicare cost-sharing payments.

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