Prohibition on Billing Dually-Eligible Members Enrolled in the Qualified Medicare Beneficiary Program
Medicare providers may not bill, charge, collect a deposit, or seek reimbursement from any Medicare and Medicaid dually-eligible members enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB program is a State Medicaid benefit that exempts Medicare beneficiaries from Medicare cost-sharing liability and covers premiums, deductibles, coinsurance and copayments for Medicaid and Medicare dually-eligible QMB members. Medicare providers must accept Medicare payments and any Medicaid payments provided as payment in full for services rendered to QMB members.
It is also against federal law (Section 1902(n)(3)(B) of the Social Security Act) for any Medicare provider, not only those that also accept Medicaid, to bill dually-eligible QMB members. Medicare providers that bill QMB members for Medicare cost-sharing are subject to sanctions per their Medicare Provider Agreement. To avoid billing QMB members for Medicare cost-sharing, Medicare providers should take the following precautions:
- Identify QMB enrolled members by looking for “Blue Cross Medicare Advantage Dual Care” on the member ID cards
- Check the New Mexico Medicaid portal to verify member QMB status
- Understand the Medicare cost-sharing billing process
- Ensure that billing software exempts QMB members from Medicare cost-sharing billing and related collections efforts
For more information regarding QMB billing, please see the following resources:
- Medicare Learning Network (MLN) MLN Matters® SE1128
- MLN Booklet: Dual Eligible Beneficiaries Under Medicare and Medicaid
- Medicaid.gov Dual Eligibles
- Medicaid.gov Seniors & Medicare and Medicaid Enrollees
Blue Cross Medicare Advantage and Blue Cross Medicare Advantage Dual Care plans are HMO, HMO-POS, PPO, and HMO Special Needs Plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program. Enrollment in HCSC’s plans depends on contract renewal.