Joe Client is disabled and lives only on SSI and SSD. His health care is covered by Medicare, and Medicaid’s Qualified Medicare Beneficiary (QMB) program picks 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. Can you help him? Does he have to pay?
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 2018 Medicare Handbook here. See p. 99.
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
See CMS Medicare Learning Network (MLN) Article: “Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles): At a Glance"
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.
NYS Provider questions about QMB billing and eligibility should be directed to the Computer Science Corporation 1-800-343-9000
The answer to this question has changed by laws enacted in 2015 and 2016. The answer is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, The answer also differs based on the type of service.
If service is an ambulance or psychologist, QMB/Medicaid will pay full coinsurance, regardless of what the Medicaid rate is for the service. SSL 367-a, subd. 1(d)(iii)-(iv), as amended 2015 and 2016.
Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate:
SSL 367-a, subd. 1(d)(iii), 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 proposal and the final budget provision. he Medicare rate for Mary's specialist visit is $200, of which her Medicare Advantage plan pays $150 and Mary is charged a copayment of $50. The Medicaid rate for the same service is $150.
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 December 2017.
CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing
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.
QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits.
Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.
Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.
COMING IN 2018 - CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017).
In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans.
Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link. Their information includes:
Various toolkits, fact sheets etc. The toolkit has model letters to providers to explain QMB rights. both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters
The 2017 Medicare Handbook, for the first time, gives information about QMB Protections. Download the 2018 Medicare Handbook here. See p. 99.
Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.
Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights. both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters . Include a link to the CMS Medicare Learning Network Notice: Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised Dec. 2017)
In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372.
Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs.
September 4, 2009, updated Dec. 15,, 2017 by Valerie Bogart, NYLAG
Author: Cathy Roberts ;
Author: Geoffrey Hale
This article was authored by the Empire Justice Center.