CMS Releases Informational Bulletin Regarding Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)

January 6, 2012
The Centers for Medicare and Medicaid Services released an informational bulletin with information on the prohibition on "balance-billing" Qualified Medicare Beneficiaries (QMBs) for Medicare cost-sharing, including deductible, coinsurance, and copayments.

QMBs are people who are entitled to Medicare Part A and are eligible for Medicare Part B, have incomes below 100 percent of the Federal Poverty Level, and have been determined to be eligible for QMB status by their state Medicaid Agency. Medicaid pays for Medicare Part A and B premiums, deductibles, and co-payments for these qualified individuals. Medicare providers are prohibited from balance-billing QMBs for Medicare cost-sharing under Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997.

Providers who serve QMBs must bill the state Medicaid Agency for any cost-sharing amounts the state must cover. The claims process can be improved through effective communications between state Medicaid agencies and QMB providers. Some strategies are provided to improve this communication, including:

• Offer separate enrollment forms for QMB-only providers, or allow providers to identify as “QMB-only” on provider enrollment applications.
• Include guidance in all communications with QMB providers to emphasize that balance- billing of QMBs is a violation of the provider’s Medicare agreement.
• Provide clear guidelines for QMB providers on Medicaid provider enrollment and billing processes.

The informational bulletin can be read in full here.