Qualified Medicare Beneficiary (QMB) Program

Date: May 8, 2021

The QMB program provides Medicaid coverage of Medicare Part A and Part B premiums and cost-sharing to low-income Medicare beneficiaries. QMB is an eligibility category under the Medicare Savings Programs.  All Medicare suppliers and providers — even those that do not accept Medicaid — must refrain from billing QMBs for Medicare cost-sharing for Parts A, and B covered services. The QMB billing restrictions apply to all QMB, including those enrolled in Medicare Advantage plans and original Medicare.

Providers and suppliers can use Medicare eligibility data provided to Medicare providers, suppliers, and their authorized billing agents (including clearinghouses and third-party vendors) by CMS’ HETS to verify a patient’s QMB status and exemption from cost-sharing charges. Providers can ask their third party eligibility-verification vendors how their products reflect the QMB information from HETS. For more information, you can visit the HETS website.

Medicare providers and suppliers can readily identify the QMB status of patients and billing prohibitions from the Medicare Provider Remittance Advice, which will contain notifications and information about a patient’s QMB status. For more information, see Reinstating the QMB Indicator in the Medicare Fee-For-Service (FFS) Claims Processing System from CR 9911 MLN Matters Article.

MA providers and suppliers should also contact the MA plan to learn the best way to identify the QMB status of plan members. Providers and suppliers may also verify a patient’s QMB status through State online Medicaid eligibility systems or other documentation, including Medicaid identification cards, Medicare Summary Notices, and documents issued by the State proving the patient is enrolled in the QMB program.

If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare RA. For more information, see Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program MLN Matters Article

We are available and happy to assist you with issues such as this and other topics related to eye care reimbursement.  We are still presenting our training webinars related to changes in 2021 on Evaluation and Management eye exam coding.  We are pleased to announce that we have 2 new webinars on chart documentation and auditing for the 2021 E/M guidelines.  Contact us if you are interested.

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