Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare Cost-Sharing

Members & Publications


November 10, 2016

Medicare Administrative Contractors (MACs) have been instructed to issue a compliance letter instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing with regard to improper QMB billing. Federal law bars Medicare providers from charging individuals enrolled in the Qualified Medicare Beneficiary Program (QMB) for Medicare Part A and B deductibles, coinsurances, or copays. QMB is a Medicaid program that assists low-income beneficiaries with Medicare premiums and cost-sharing. 

QMB billing can be confusing because although Medicaid is, in effect, the secondary or supplemental payer who would ordinarily be expected to pay for the Medicare deductible and co-insurance, individual state Medicaid programs may have a rule that they will not pay anything more once their usual payment level has been reached. Since Medicare generally pays more than Medicaid, it is entirely possible that the amount paid by Medicare will already be greater than what Medicaid would have paid, therefore they will not send any further reimbursement. Where providers err is in then billing the patient for the co-pay or co-insurance, which is not permitted. For further information, please view this slide presentation.

Legislation Introduced to Alleviate Impact of Conversion Factor Cut for 2021

Nov 09, 2020

Last month, two bills were introduced in the House proposing solutions to the estimated 10.6% Physician Fee Schedule conversion factor cut expected to go into effect January 1, 2021.  The bills offer some relief to the cut, but do not reflect a comprehensive or long-term solution.  AAPM&R has therefore chosen to remain neutral regarding these bills. 

Your Academy continues to advocate for a permanent solution to the conversion factor cut while maintaining the important payment increases to office and outpatient evaluation and management services.