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BALANCE BILLING OF QMB MEMBERS IS PROHIBITED
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The Qualified Medicare Beneficiary (QMB) program is a Medicaid program for Medicare beneficiaries. QMB individuals cannot be charged for Medicare cost sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments, but federal law allows states to limit provider reimbursement for Medicare cost sharing under certain circumstances. 

Dually eligible individuals may qualify for Medicaid programs that pay Medicare Part A and B premiums, deductibles, coinsurance and copays to the extent provided by the state Medicaid plan. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services to a QMB individual. 

Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions

Be aware of these policy clarifications to help ensure compliance with QMB balance billing requirements:

  • All Original Medicare and Medicare Advantage providers — not just those that accept Medicaid — must abide by the balance-billing prohibitions.
  • QMB individuals retain their protection from balance billing when they cross state lines to receive care. Providers can’t charge QMB individuals even if their QMB benefit is provided by a state that is different from the one where care is received.

For more information about dual eligible categories and benefits, visit CMS’s website.

For more on the QMB program and other individuals dually eligible for Medicare and Medicaid benefits, see the Medicare Learning Network® publication.

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Insights
August 2018