Q What is the Qualified Medicare Beneficiary Program?

A The QMB program is a Medicare Savings program that exempts Medicare beneficiaries from Medicare cost-sharing liability. Established as part of the Medicare Catastrophic Coverage Act in 1988, the program is a state Medicaid benefit that covers Medicare deductibles, co-insurance and co-payments.

Federal guidelines set an eligibility floor based on the federal poverty level and the value of a beneficiary’s resources. States can choose to make these limits more generous and include more beneficiaries in their programs, in the same way that they can expand welfare benefits. In some states, the QMB program also pays the beneficiary’s Medicare premium, especially where there are dual-eligible managed-care plans.

Q Is it important for practices to identify QMB-enrolled patients?

A Yes. Under federal law, patients enrolled in the QMB program are exempt from liability for Medicare deductibles, co-insurance or co-payments. QMB applies to all Part B, Part C and DMEPOS claims. Balance-billing QMB-enrolled patients would be a violation of your Medicare provider agreement and could subject you to sanctions. CMS published a “reminder” MLN Matters SE1128 (Revised) on May 12, 2017, which “. . . reminds all Medicare providers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing.”

Q Do QMB program limitations apply to Medicare Advantage Plans?

A Yes. The QMB program applies to Medicare Advantage (Medicare Part C) patients as well as those enrolled in regular Medicare (Part B). You may not collect an Advantage Plan co-payment from a QMB program enrollee.

Q Are non-participating Medicare providers subject to the QMB program rules?

A The QMB program applies to all Medicare providers, both participating and non-participating.  Further, you are obliged to accept assignment on all services to these patients, even if you would not do so otherwise. By accepting assignment, you agree to accept the Medicare and Medicaid payment as payment in full, regardless of whether Medicaid pays or not.

Q If we are not Medicaid providers, are we required to adhere to the QMB program rules?

A Even if you are not enrolled as a Medicaid provider, you are still subject to the QMB program limitations. Because Medicaid won’t pay you if you aren’t enrolled, Medicare cost-sharing balances must be written off and may not be billed to QMB program enrollees.

Q What if Medicaid does not pay even though we are enrolled providers?

A Even if Medicaid doesn’t reimburse, you remain prohibited from charging QMB program individuals for Medicare cost-sharing and must write off the balance. It’s not uncommon to find that states set their fee schedules at or below the Medicare payment amount, limiting the state’s liability to providers.  

Q How do we identify patients enrolled in the QMB program?

A The May 12, 2017 transmittal states the following regarding ways to improve processes related to QMBs.

“Determine effective means to identify QMB individuals among your patients, such as finding out the cards that 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. MA providers should contact the plan to determine how to identify the plan’s QMB enrollees. Beginning October 1, 2017, you will be able to readily identify the QMB status of your patients with new Medicare Fee-For-Services improvements. Refer to Fee-For-Service Claims Processing System for more information about these improvements.

Q Are there any indicators on our Remittance Advice to identify QMB program patients?  

A Yes, there are three RA codes to look for when claims are paid.  

•  N781 – No deductible may be collected.
•  N782 – No coinsurance may be collected.
•  N783 – No co-payment may be collected.

Each of these also instructs you to “Review your records for any wrongfully collected amounts above.”

Q If the patient we’re seeing is from out of state, does QMB status still apply to us?

A Yes. QMB program enrollees retain their protection against cost-sharing when they cross state lines to receive care. You may not balance-bill QMB program patients even if their Medicaid is provided by a state other than the state in which care is rendered.

Q May a patient choose to waive his QMB status?

A No. QMB patients cannot choose to waive their QMB status and pay Medicare cost-sharing.  One exception may be for explicitly non-covered services (i.e., cosmetic services or refractive care). Prior to seeking payment from patient for these non-covered services, be certain that their plan (Medicare, Medicaid or MA) considers these services non-covered. Best practice would be to secure something in writing from the plan and from the patient acknowledging his financial responsibilities.  

Q Are Medicaid billing processes the same from state to state?

A No. You need to determine the process to bill Medicaid for reimbursement of the beneficaries’ cost-sharing. Different processes may apply for QMB program beneficiaries. Most states have electronic processes with regular Medicare so these claims automatically cross over to Medicaid. If crossed over, it is noted on the Medicare remittance advice. In order to receive payment, you must be enrolled as a Medicaid provider.  

Q What steps should we take to be compliant with QMB program rules?

A Staff should be able to identify enrolled patients and designate them as QMB-program-enrolled patients in the practice’s billing software system. With the appropriate flag in the system, these patients should not be asked to pay deductibles, co-payments or co-insurance amounts, or be included in the practice’s collection efforts.   REVIEW

Ms. McCune is the Executive Director for the Society for Excellence in Eyecare. Contact her at DonnaMcCune@outlook.com.