Billing for Dually Eligible Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) has once again issued guidance reminding providers that federal law bars Medicare providers from billing a Qualified Medicare Beneficiaries (QMB) under any circumstances.

Concerned with provider non-compliance, CMS once again issued a reminder that Medicare providers may not bill dually eligible beneficiaries enrolled in the QMB Program for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. This prohibition on charging QMBs for Medicare cost sharing applies not only to all original Medicare but also to Medicare Advantage providers, regardless of whether they accept Medicaid.

Providers are required to accept Medicare/Medicare Advantage and Medicaid payment (whatever the amount may be) as payment in full. Providers who inappropriately bill QMB individuals may be in violation of their provider agreement and could be subject to sanctions.

The Qualified Medicare Beneficiary is a Medicaid program for Medicare beneficiaries which exempts beneficiaries from having to pay Medicare cost sharing, including deductibles, co-insurance and copayments. While State Medicaid programs may pay providers for Medicare cost sharing they are permitted by Federal law to limit their reimbursement amounts.

For example, the New York State Medicaid Program recently announced that Medicaid will no longer reimburse the full Medicare Part C copay or coinsurance amount on Part C claims retroactive to July 1, 2016. The new changes to the law are set to be implemented on or about May 25, 2017, will only reimburse 85% of the copay or the coinsurance of the institutional, professional as well as pharmacy claims for drugs and supplies. The law, however, does not effect reimbursements of Medicare Part C deductibles as Medicaid will continue to reimburse those cost-sharing amounts. The law also does not apply to ambulance providers and psychologists who will continue to be receive the full Medicare Part C copay and coinsurance amounts.

If you have questions about QMB, the Medicare or Medicaid Programs, enrollment, revalidation, exclusions, reinstatement or have other health law questions, please contact our office.