As part of the AMA’s ongoing work with the Centers for Medicare & Medicaid Services on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed their concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition. The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries—e.g., individuals who are enrolled in both Medicare and Medicaid—with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers—even those who do not accept Medicaid—from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.
For further information, see the article below.
Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program
This article from the Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing (such charges are known as “balance billing”). QMB is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability.
The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain circumstances.) Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers –not only those that accept Medicaid–must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions.
Please ensure that you and your staffs are aware of the federal balance billing law and policies regarding QMB individuals. Contact the Medicaid Agency in the States in which you practice to learn about ways to identify QMB patients in your State and procedures applicable to Medicaid reimbursement for their Medicare cost-sharing. If you are a Medicare Advantage provider, you may also contact the MA plan for more information. Finally, all Medicare providers should ensure that their billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts.
This article provides CMS guidance to Medicare providers to help them avoid inappropriately billing QMBs for Medicare cost-sharing, including deductibles, coinsurance, and copayments. This practice is known as “balance billing.”
Balance Billing of QMBs Is Prohibited by Federal Law
Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances. See Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997. (Please note, this section of the Act is available at http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.)
QMB is a Medicaid program for Medicare beneficiaries that exempt them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. However, as permitted by federal law, States can limit provider reimbursement for Medicare cost-sharing under certain circumstances. See the chart at the end of this article for more information about the QMB benefit.
Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.)
Inappropriate Balance Billing Persists
Despite federal law, erroneous balance billing of QMB individuals persists. Many beneficiaries are unaware of the billing restrictions (or concerned about undermining provider relationships) and simply pay the cost-sharing amounts. Others may experience undue distress when unpaid bills are referred to collection agencies. See Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), Centers for Medicare & Medicaid Services July 2015 at https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Access_to_Care_Issues_Among_Qualified_Medicare_Beneficiaries.pdf on the CMS website.
Important Clarifications Concerning QMB Balance Billing Law
Be aware of the following policy clarifications to ensure compliance with QMB balance billing requirements. First, know that all original Medicare and MA providers– not only those that accept Medicaid– must abide by the balance billing prohibitions.
In addition, QMB individuals retain their protection from balance billing when they cross state lines to receive care. Providers cannot charge QMB individuals even if the patient’s QMB benefit is provided by a different State than the State in which care is rendered.
Finally, note that QMBs cannot choose to “waive” their QMB status and pay Medicare cost-sharing. The federal statute referenced above supersedes Section 3490.14 of the “State Medicaid Manual,” which is no longer in effect.
Ways to Improve Processes Related to QMBs
Proactive steps to identify QMB individuals you serve and to communicate with State Medicaid Agencies (and Medicare Advantage plans if applicable), can promote compliance with QMB balance billing prohibitions.
1. Determine effective means to identify QMB individuals among your patients. Find out what cards are issued to QMB individuals so you can in turn ask all your patients if they have them. Learn if you can query state systems to verify QMB enrollment among your patients. If you are a Medicare Advantage provider contact the plan to determine how to identify the plan’s QMB enrollees.
2. Discern what billing processes apply to seek reimbursement for Medicare cost-sharing from the States in which you operate. Different processes may apply to original Medicare and MA services provided to QMB beneficiaries. For original Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordination & Recovery Center (BCRC) to automatically receive Medicare-adjudicated claims.
• If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare Remittance Advice.
• Understand the processes you need to follow to request reimbursement for Medicare cost-sharing amounts if they are owed by your State. You may need to complete a State Provider Registration Process and be entered into the State payment system to bill the State.
3. Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts.
Additional Information
For more information about dual eligible categories and benefits, please visit http://www.medicare.gov/Publications/Pubs/pdf/10126.pdf. Also, for more information about QMBs and other individuals who are dually eligible to receive Medicare and Medicaid benefits, please refer to the Medicare Learning Network® publication titled “Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles),” which is available on the CMS website.
For general Medicaid information, please visit the Medicaid webpage at http://www.medicaid.gov/index.html on the CMS website.
