Reminder: Medicare Providers May Not Bill Participants in the Qualified Medicare Beneficiary Program

December 19, 2019

As a Medicare provider, you may not bill individuals enrolled in the Qualified Medicare Beneficiary Program (QMB), a federal Medicare Savings Program.

Individuals enrolled in QMB are dual eligible beneficiaries, which means they are eligible for both Medicare and Medicaid. As a State Medicaid benefit, QMB covers the Medicare premiums, deductibles, coinsurance and copayments of QMB beneficiaries. QMB beneficiaries are not responsible for Medicare cost-sharing, or out-of-pocket costs.

Your Responsibility
Providers participating in Blue Cross Medicare AdvantageSM plans may not bill their QMB patients for services provided to them, regardless of whether the State reimburses the full Medicare cost-sharing amounts. You must bill both Medicare and Medicaid, and accept Medicare payments and any Medicaid payments as payment in full.

Federal Law
Please ensure that you and your staff are aware of the federal billing law and policies governing QMB. It is against federal law for any Medicare provider to bill QMB patients, whether or not the provider accepts Medicaid. Per your Medicare Provider Agreement, you may be sanctioned if you inappropriately bill QMB patients for Medicare cost-sharing.

Helpful Tips
To avoid billing QMB patients, please take these precautions:

  • Identify QMB patients by looking for Blue Cross Medicare Advantage Dual CareSM or Blue Cross Medicare Advantage Dual Care PlusSM on their ID cards
  • Check the New Mexico Medicaid portal Learn more about third-party links to confirm QMB beneficiary status
  • Understand the Medicare cost-sharing billing process
  • Be sure your billing software and staff remove QMB patients from Medicare cost-sharing billing and related collections efforts

More Information
Call Customer Service at 1-877-774-8592 to learn more about QMB procedures and ways to identify QMB patients. For more details about QMB, see the Centers for Medicare & Medicaid Services website Learn more about third-party links.

HMO, 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.