Billing and cost-sharing for individuals enrolled in the Qualified Medicare Beneficiary program

June 5, 2020

As a reminder, the Qualified Medicare Beneficiary (QMB) program is a state Medicaid benefit that pays Medicare premiums and cost-sharing for certain low-income Medicare beneficiaries. For enrollees who are eligible for both Medicare and Medicaid, you may bill the state for applicable Medicare cost-sharing. However, such payments are subject to individual state payment limits.

Federal law states that Medicare providers may not collect Medicare Part A and Medicare Part B cost-sharing (i.e., copayments, coinsurance, or deductibles) from those enrolled in the QMB program, regardless of whether the state reimburses the provider in full for the cost-sharing. Therefore, we would like to remind you that when billing AmeriHealth for services rendered to these members, you must accept our reimbursement, according to your Agreement with AmeriHealth, as payment in full. All Original Medicare and Medicare Advantage providers — not only those who accept Medicaid — must abide by these billing prohibitions. Medicare providers who do not follow these billing prohibitions may be violating their Medicare Provider Agreement and may be subject to sanctions.

Identifying QMB members

On the NaviNet® web portal (NaviNet Open), select the appropriate health plan for the member from the Workflows menu and then the Eligibility and Benefits Inquiry transaction. Then, from the Eligibility and Benefits Details Screen, select Health Benefit Plan Coverage from the Benefits menu. “QMB MEMBER” will be indicated within the Co-Insurance and Out-of-Pocket Max sections. The QMB indicator will also be returned through the EDI 271 transaction.

 

In addition, providers are reminded that discrimination against beneficiaries based on their payment status is prohibited.

Learn more

For more information, read the article Prohibition Billing Dually Eligible Individuals Enrolled in the QMB Program on the Centers for Medicare & Medicaid Services' website.

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