"Qualified Medicare Beneficiaries" (QMB) - Protections against "Balance Billing"

THE PROBLEM:  Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance

Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB).   His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations.  Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services.   He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay.  Now Joe has a bill that he can’t pay.   Read below to find out --


QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider.  Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.  This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service.  However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance.  Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers.   Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries.  Even those who know may pressure their patients to pay, or simply decline to serve them.   These rights and the ramifications of these QMB rules are explained in this article. 

CMS is doing more education about QMB Rights.  The 2017 Medicare Handbook, for the first time, gives information about QMB Protections.   Download the 2019 Medicare Handbook here. See p. 99.  

1.  To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?  

According to a CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance. The bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules."   If the provider chooses not to enroll as a Medicaid provider, it still may not "balance bill" the QMB recipient for the coinsurance.  

2.   How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?

If beneficiary has Original Medicare --

The provider bills Medicaid  - even if the QMB Beneficiary does not also have Medicaid.   Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid  (ie, chiropractic, podiatry and clinical social work care).  Whatever reimbursement Medicaid  pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C. § 1396a(n)(3)(A),  NYS DOH 2000-ADM-7

If the QMB beneficiary is in a Medicare Advantage plan -

The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan.  

3.  For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?

The answer to this question has changed by laws enacted in 2015 and 2016.  In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further.   The amount Medicaid pays  is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan,  with better payment for those in Medicare Advantage plans.  The answer also differs based on the type of service. 

  1. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1364 in 2019) and Skilled Nursing Facility coinsurance ($170.50/day) for days 20 - 100 of a rehab stay.  Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down.  Payments are reduced if the beneficiary has a Medicaid spend-down.   For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met.  For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200).   See more on spend-down here

  2. Medicare Part B

    1. Deductible  -  Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $185 in 2019.   For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $185.  Medicaid pays the entire $185, meeting the deductible.  If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.  

      • In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below.   This proposal was REJECTED by the state legislature. 

    2. Co-Insurance -  The amount medicaid pays is different for Original Medicare and Medicare Advantage. 

      • If individual has Original Medicare, QMB/Medicaid will pay only to the extent the provider's total payment from Medicare and Medicaid does not exceed the Medicaid rate for the service.  Medicaid will not pay any of the 20% Part B coinsurance, if the Medicaid rate is more than 20% lower than the Medicare rate for the service. For example, if the Medicare rate for a service is $100,  the coinsurance would be $20.  If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid.

Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate: 

SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015

EXCEPTIONS:  The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate: 

Example to illustrate the current rates.   The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120.  

4.   May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?

No.  Balance billing is banned by the Balanced Budget Act of 1997.   42 U.S.C. § 1396a(n)(3)(A).   In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance.  This is true whether or not the provider is registered as a Medicaid provider.  If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.  This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing.  The CMS letter states,

"All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at: CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing.  Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.  Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b),  which is no longer in effect, but may be causing confusion about QMB billing."

The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018.

CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals.  See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 

5.  How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?

It can be difficult to show a provider that one is a QMB.  It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems

   6.  If you are Billed  -​  Strategies 

Toolkit to Help Protect QMB Rights

September 4, 2009, updated Dec. 15,, 2017 and Jan. 26, 2019 by Valerie Bogart, NYLAG

Author: Cathy Roberts ;

Author: Geoffrey Hale 

This article was authored by the Empire Justice Center.

Empire Justice Center

Article ID: 94
Last updated: 16 May, 2019
Revision: 18
Medicare Savings Program -> "Qualified Medicare Beneficiaries" (QMB) - Protections against "Balance Billing"