Quiet My Brain regarding the Qualified Medicare Beneficiary (QMB)

QMB? OMG!

Many offices seem unaware of the acronym “QMB.” And even those who are aware can be challenged with understanding how this impacts their office. QMB stands for Qualified Medicare Beneficiary – a patient that is dually eligible for Medicare and Medicaid. It is important to note that not all patients with Medicare and Medicaid will qualify as a QMB patient.

Most states have specific rulings on how to process QMB patients, but before investigating further, it is important to determine if the patient is a part of this program. QMB information will not be found on the patient’s Medicare card, but it “may” appear in the top right-hand portion of their Medicaid card. It is important not to rely upon the information found on the patient’s ID card as the QMB status is based on financial need which can change monthly.

How Do I Determine QMB Status?

Beginning in July 2018, the necessary information to determine QMB Status became available on the remittance advice for Fee for Service (FFS) providers with traditional Medicare. Medicare Advantage (MA) providers should contact the MA plan to see how to identify the QMB status of members both before and after claims submission. We recommend utilizing the HIPAA Eligibility Transaction System (HETS) for health care eligibility benefit inquiry and response. The information on HETS will be accurate only for the time of the transaction; therefore, it is wise to check periodically on this status throughout the patient’s care in your office. Another resource is the state online Medicaid eligibility systems since the state is the entity that assigns the QMB status for individuals who qualify. If the HETS response indicates the QMB status has terminated, refer to the state’s online Medicaid eligibility systems to verify.

There can be varying levels of the QMB status which can range from the patient having $0 responsibility for covered services to a preset co-payment. QMB-enrolled patients are not liable for Medicare co-insurance, co-payments or deductible payments; however, patients are responsible for non-covered services if they receive advanced notification that the service is not covered. To charge the patient for non-covered services, the office is required to notify the patient in advance of these services and charges; this is separate from the Medicare ABN form. It is imperative to verify if your state Medicaid program has their own financial responsibility/waiver form the patient must sign prior to receiving the service before utilizing any internal office form. Please note that blanket non-covered service forms at the beginning of care usually will not satisfy the notification requirements for any payer.

What About Supplemental Medicare Policies?

If a Medicare supplemental policy exists in addition to Medicare and Medicaid, Medicaid will be the tertiary payer. If the covered service is not paid in full by Medicare and the supplement policy, the patient cannot be charged for the deductible, co-payment or co-insurance assessed by Medicare. It is typical for the allowable fee of Medicaid to be less than the Medicare allowable fee; therefore, do not expect to always see the 20% co-insurance with traditional Medicare paid by Medicaid. When the patient has a QMB status, the patient is not responsible for the co-insurance and this will be a contractual obligation write off in your office. But My Office Doesn’t Participate with Medicaid These rules still apply for offices who do not participate with Medicaid. As per CMS, “All Original Medicare and MA providers and suppliers–not only those that accept Medicaid– must not charge individuals enrolled in the QMB program for Medicare cost-sharing. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions. Providers and suppliers may bill State Medicaid programs for these costs, but States can limit Medicare cost sharing payments under certain circumstances.”

It is Federal law that prevents you from collecting from a QMB patient; however, Medicaid is a state program. Be sure to verify how the QMB program works with the individual state. Most states have published rules regarding the QMB program on their web portals. The state of West Virginia states in their online Provider manual: “”A provider must accept Medicaid payment as payment in full for covered services. A claim is considered paid in full even when the actual Medicaid payment is zero dollars. If the Medicaid payment has been reduced to zero due to payments from Medicare or private insurance, it will be considered paid in full… Providers are prohibited from imposing any additional charges on the member above the Medicaid allowable reimbursement amount. This does not include Medicaid co-payments, if applicable.” They also go on to say in 800.13 of the same manual that “Medicaid members are not responsible for any third party related co-insurance amounts, deductible amounts, or HMO related Co-pays and deductibles, even if the claim payment is zero when the claim payment has been reduced as a result of the insurance payment or capitation agreement.”

In 2016, 7.5 million individuals were enrolled in the QMB program

Always be sure to verify each patient’s eligibility prior to the start of care and throughout the duration of care since this status is subject to change monthly. Providers who inappropriately charge those enrolled as a QMB for covered services will be subject to sanctions.

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