Certain patients are in a special category known as “Qualified Medicare Beneficiary” (QMB) that affects how you treat them financially. Here are the considerations you need to address in your practice.
Q. What is a Qualified Medicare Beneficiary?
A. As part of the Medicare Catastrophic Coverage Act of 1988, CMS created the QMB program. It is a state Medicaid benefit that covers Medicare deductibles, coinsurance and copayments. Federal guidelines set an eligibility floor based on the federal poverty level and the value of a beneficiary’s resources (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf ). States can choose to make these limits more generous and include more beneficiaries in their programs, just as they can expand welfare benefits.
In some states, the QMB program also pays the beneficiary’s Medicare premium, especially where there are dual-eligible managed care plans.
Q. Why is it important to properly identify these patients?
A. Under federal law, patients who are enrolled in the QMB program are exempt from liability for Medicare deductibles, coinsurance or copayments (collectively, “cost-sharing”). QMB applies to all Part B (regular Medicare), Part C (Medicare Advantage) and DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) claims. You may not charge or collect any amount from these patients under any circumstances. Balance-billing these patients would be a violation of your Medicare provider agreement and could subject you to sanctions.
Q. If we are not a participating provider with Medicare, are we still subject to QMB?
A. The QMB program applies to all Medicare providers, both participating and non-participating. Further, you are obliged to accept assignment on all services to these patients even if you would not do so otherwise. Remember that accepting assignment means that you agree to accept the Medicare and Medicaid payment as payment in full, regardless of whether Medicaid pays or not.
Q. Are we still subject to QMB limitations if we are not Medicaid providers?
A. Even if you are not enrolled as a Medicaid provider, you are still subject to the QMB limitations. Because Medicaid will not pay you if you are not enrolled, Medicare cost-sharing balances must be written off and therefore can’t be billed to QMB patients.
Q. What if Medicaid does not pay, even if we are enrolled providers?
A. States may limit their liability to providers, usually by setting their fee schedules at or below the Medicare payment amount. Even if Medicaid does not pay, you are still prohibited from charging QMB individuals for Medicare cost-sharing and must write off the balance.
Q. If the patient we are seeing is from out-of-state, does QMB still apply to us?
A. QMB individuals retain their protection against cost-sharing when they cross state lines to receive care. You may not balance bill QMB patients even if their Medicaid is provided by a state other than the state in which care is rendered.
Q. Suppose the patient wants to pay us outside of any insurance; can we do that?
A. Maybe, but tread carefully. Remember that many Medicaid programs cover services that Medicare does not, and that Medicare Advantage plans also offer additional coverage (eg, routine eye care). QMB patients cannot choose to waive their QMB status and pay Medicare cost-sharing, so you could be accused of balance-billing — a serious offense.
Only if you are absolutely sure that a service is not covered could you collect from the patient; we recommend getting something in writing.
Q. How do we identify these QMB patients?
A. It is clearly best to know in advance; some states make obtaining the status easier. When it’s not possible (such as when the state has not updated the status list and you are checking today for today’s exam), there are now two Remittance Advice (RA) codes to look for:
- N781 – Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to subsequent payer.
- N782 – Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected co-insurance. This amount may be billed to subsequent payer.
Q. Does Medicare offer any other advice?
A. CMS has issued an FAQ that gives additional resources (https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-06-06-QMB-Call-FAQs.pdf ) and recommends the following:
- Determine effective means to identify QMB patients. Find out which cards or other forms of identification are issued to QMB individuals so you can ask your patients if they have them. Some state systems have online inquiry systems to verify QMB enrollment. Contact your Medicare Advantage plans to determine how to identify their enrollees.
- As of November 2017, CMS notes that providers can use the HETS (HIPAA Eligibility Transaction System) to identify Medicare QMB eligibility (tinyurl.com/mh2jxfr4 ); HETS enrollment is required. For example, MAC First Coast (Florida) states “If the beneficiary is enrolled as a Qualified Medicare Beneficiary (QMB), deductible information may not be available at the time of the query.” “HETS (HIPAA Eligibility Transaction System) indicates periods during which the beneficiary is enrolled as a QMB and will indicate the beneficiary owes $0 for Medicare Part A and B deductibles, coinsurance or copayments. Note: This information will be displayed under the QMB tab within SPOT [search provider online tool].”
- Find out what you need to do to bill Medicaid for reimbursement of the beneficiaries’ cost-sharing, as there may be different processes for these patients. Nearly all states have electronic processes with Medicare, so these claims automatically cross over to Medicaid; you will see this noted on your Medicare remittance advice. Remember that you must be enrolled with Medicaid for payment.
- Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and collection efforts. OM
