Qualified Medicare Beneficiary Program Member Billing Protection

The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing (Medicare Part A and Part B coinsurance, copayments, and deductibles) to low-income Medicare beneficiaries as determined by federal law. CMS prohibits Medicare providers and suppliers, including pharmacies from collecting cost-sharing liabilities from members enrolled in the QMB Program.

Ways to identify QMB status of MA members

• Use the Medicare 270/271 HETS data provided to Medicare providers, suppliers, and their authorized billing agents (including clearinghouses and third-party vendors effective November 2017) to verify a beneficiary’s QMB status and exemption from cost-sharing charges. Ask your third-party eligibility-verification vendors how their products reflect the new QMB information from HETS. For more information, visit the HETS website.
• Providers and suppliers may also verify beneficiaries’ QMB status through automated Medicaid eligibility-verification systems in the State in which the person is a resident or by asking beneficiaries for other proof, such as their Medicaid identification card, MSN (starting July 2018) or other documentation of their QMB status.

Providers and suppliers may bill State Medicaid programs for these costs. Providers who do not follow these billing prohibitions would be noncompliant with Center for Medicare and Medicaid Services (CMS).

References:

1. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/QMBRAandEOBMemo04032018.pdf [PDF]
2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf [PDF]

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