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

​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. 

According to your Agreement with AmeriHealth, you must accept our reimbursement as payment in full when billing for services rendered to these members. 

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 PEAR portal, select the Practice Management application. Use the Eligibility & Benefits transaction to search for the member. From the Details screen, select the Benefits & Coverages tab. “QMB MEMBER" will be indicated within the Out-of-Pocket section. The QMB indicator will also be returned through the EDI 271 transaction.




It is prohibited to discriminate against beneficiaries based on their payment status.

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.