Reminder: Medicare Providers May Not Bill Participants in the Qualified Medicare Beneficiary Program
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.
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.
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.
To avoid billing QMB patients, please take these precautions:
- Identify QMB patients by looking for Blue Cross Medicare Advantage Dual CareSM on their ID cards
- Check the Texas Medicaid portal 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
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.
HMO, PPO, and HMO Special Needs Plans are provided by HCSC Insurance Services Company (HISC). HMO plans are provided by GHS Insurance Company (GHS). HMO and PPO employer/union group plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). HCSC, HISC and GHSIC are Independent Licensees of the Blue Cross and Blue Shield Association. HCSC and HISC are Medicare Advantage organizations with a Medicare contract. GHS is a Medicare Advantage organization with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in these plans depends on contract renewal.
The information provided here is only intended to be a summary of the law that has been enacted and is not intended to be an exhaustive description of the law or a legal opinion of such law. If you have any questions regarding the law mentioned here, you should consult with your legal advisor.