Important Reminder about Billing Requirements for Certain Dual-Eligibles

July 7, 2016

The American Medical Association (AMA) has asked the Academy to remind members 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 more information, please visit MLN Matters, Prohibition on Balance Billing Dually-Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.  

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