Qualified Medicare Beneficiary program billing requirements

Physicians participating in the Medicare program are prohibited from billing a Qualified Medicare Beneficiary (QMB) for any Medicare Part A/B premiums or cost-sharing under any circumstances. Patients enrolled in the QMB program—which is an eligibility category that the Centers for Medicare & Medicaid Services (CMS) offers to assist low-income patients under the Medicare Savings Program—are eligible to receive Medicaid coverage for out-of-pocket costs for Medicare services, including deductibles, copayments, and coinsurance. In 2016, 7.5 million people—more than one out of eight Medicare beneficiaries—were enrolled in the QMB program.* Of that total, more than three-fourths received full Medicaid benefits in addition to coverage for their Medicare Part A/B expenses.

In recognition of the difficulties associated with identifying patients’ QMB status and billing for services provided to such patients, this column outlines the restrictions on physicians’ ability to seek reimbursement for cost-sharing amounts from QMB enrollees and describes how practices can ensure they are in compliance with QMB billing rules.

What billing requirements apply to physicians who treat QMB patients?

All Medicare fee-for-service (FFS) and Medicare Advantage (MA) providers—including those who do not accept Medicaid—must refrain from charging individuals enrolled in the QMB program for Medicare cost-sharing on Part A/B services and drugs. Physicians who inappropriately bill QMB patients may be subject to CMS penalties.

How can physicians ensure that they are complying with QMB billing rules?

Physicians can take the following actions to comply with QMB requirements:

  • Verify the QMB status of a patient prior to billing.
  • Ensure QMBs are not billed for Medicare charges by either the physician practice or a third-party vendor. In the event that a physician has incorrectly billed a patient enrolled in the QMB program, all charges (including referrals to collection agencies) should be immediately recalled or refunded.
  • Identify the appropriate processes for submitting QMB cost-sharing bills to state Medicaid agencies or other secondary payors. For FFS Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordination and Recovery Center to automatically receive Medicare-adjudicated claims. Different processes may apply for MA services.

How can physicians who participate in the Medicare FFS program identify the QMB status of their patients?

Physicians may verify a patient’s QMB status through the following methods:

  • Use online state Medicaid eligibility systems or CMS’ HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (also known as HETS), which provides real-time Medicare eligibility data to determine a beneficiary’s QMB status and cost-sharing liability.
  • Ask patients to present their Medicare identification cards or Medicare Summary Notices, which are sent to beneficiaries to inform them of their QMB status and billing protections, during an office visit.
  • Review Medicare Remittance Advice Remake Codes (RARCs), which are documents containing itemized information regarding Medicare payment determinations, for the following QMB-specific Alert RARCs:
    • N781–Alert: Patient is a Medicaid/Qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payor.
    • N782–Alert: Patient is a Medicaid/Qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance.

How do MA plans notify physicians of patients’ QMB status?

Sharing of information differs for each MA plan. CMS has recommended that plans inform physicians about patients’ QMB status and exemption from cost-sharing, but has not mandated any specific methods for QMB verification.

Physicians participating in an MA plan should contact the plan directly to learn the best way to identify the QMB status of enrollees before claims are submitted.

Can physicians seek payment for Medicare cost-sharing for QMBs from state Medicaid agencies?

Physicians may use Medicare RARCs to bill state Medicaid agencies and other secondary payors outside the Medicare claims crossover process for QMB cost-sharing claims. However, many states limit their payments for Medicare deductibles, coinsurance, and copays for QMBs.

States require physicians to enroll in their Medicaid system for claims review, processing, and issuance of RARCs for Medicare cost-sharing amounts under the QMB program.

Where can physicians learn more about the QMB program and applicable billing requirements?

Physicians can visit the QMB program website or review the CMS Medical Learning Network Matters article, “Reinstating the qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System,” for more information about billing processes for QMB claims.

Surgeons who have questions about complying with QMB billing requirements may contact Lauren Foe, Regulatory Associate, ACS Division of Advocacy and Healthy Policy, at lfoe@facs.org.

*Centers for Medicare & Medicaid Services. Prohibition billing dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program. June 26, 2018. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf. Accessed July 19, 2018.

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