Qualified Medicare Beneficiary (QMB) Program

"Dual-eligible beneficiaries" are individuals enrolled in both Medicare and Medicaid. This includes beneficiaries who are enrolled with Medicare Part A and/or Part B who also receive Medicaid benefits or assistance with Medicare premiums, or cost sharing through various programs. One program is the Qualified Medicare Beneficiaries (QMB) Program which assists low-income beneficiaries with their Medicare premiums and cost sharing.

Certain requirements and restrictions apply when a beneficiary is a dual eligible.

  • Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries.
  • Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of the Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance, or copayments.
    • Medicare and Medicaid payments made for services rendered to a QMB are considered as payment in full.
  • Providers cannot charge QMB individuals even if the patient's QMB benefit is provided by a different State.
  • Providers cannot update or change a patient's QMB status.
    • Monthly, but as often as daily, states submit QMB information to CMS. If a provider believes the data is incorrect, check the applicable state Medicaid eligibility system and compare it to the information received via HETS 270/271. If there is a discrepancy between the two systems, default to the state Medicaid system eligibility status.

Providers are encouraged to understand the processes required to request payment for Medicare cost-sharing amounts if they are owed by the State:

  • Providers may need to complete a State Provider Registration Process and be entered into the State payment system to bill the State.
  • All original Medicare and MA providers and suppliers–not only those that accept Medicaid–must abide by the billing prohibitions.

Note: Providers should contact the State Agency administering the program for concerns relating to the remittance advice changes and their impact on claims processing. Medicare Administrative Contractors (MACs) are unable to assist with concerns or questions beyond Medicare's processing of the claims.

QMB Deductible Clarification

QMBs are not liable for Medicare deductibles; therefore, deductible information for QMB patients is not provided via the Noridian Medicare Portal (NMP), the Interactive Voice Response (IVR), or through the Provider and/or Supplier Contact Center. Withholding the deductible prevents provider errors over their patient's status, billing, or financial records.

Noridian recommends providers contact their patient's state Medicaid agency for any questions about deductible billing. If a provider requires Medicare deductible details for their internal systems or guidelines, they may need to review their processes to determine an override or bypass for these patients.

QMB Remittance Advices

Effective October 1, 2019, CMS Medicare Learning Network (MLN) Matters (MM) 11230 - MSN Changes to Assist Beneficiaries Enrolled in the QMB Program alerted providers of further modifications to Medicare's claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiated between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.

The Remittance Advice (RA) includes two (2) Alert Remittance Advice Remark Codes (RARCs) that identify an individual currently enrolled in QMB and tells providers they may not collect deductible and coinsurance amounts from these beneficiaries. The RAs contain the QMB RARCs only in conjunction with paid claims generating Claim Adjustment Group Code Patient Responsibility (PR) and Claim Adjustment Reason Codes (CARC) 1, 2, and 66, and report Medicare deductible and coinsurance amounts so that coordination of benefits activities may result using copies of RAs if necessary. Remittance Remark Codes:

  • N781 - Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • N782 - Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

MSNs with QMB claims that are paid

  • If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will use MSN Message 62.0 to briefly explain the QMB billing protections (in the "Be Informed!" section).
  • Also, on page one, the patient's total liability amount (in the "Total You May Be billed" field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.
  • Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the "Maximum You May Be Billed" field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections.

MSNs with QMB claims that are denied

  • In the claim detail pages of the MSN, if a detail line is for a QMB and contains an allowed amount of zero, the MSN:
    • Will reflect the beneficiary's total liability amount in the "Maximum You May Be Billed" field and
    • Include new MSN 11.21 message to inform the beneficiary that even though Medicare has denied the claim, Medicaid may pay for the care.
  • Since most QMBs also have full Medicaid coverage, it's important to convey that their full Medicaid coverage may cover care that Medicare has denied.

Effective July 1, 2018, CMS reintroduced QMB information on Medicare Remittance Advices (RAs) per CMS Change Request (CR) 10433. This reinstated all changes to RAs under CR9911 without the changes that impede claim processing by secondary payers. The RAs will reflect Claim Adjustment Group Code PR (Patient Responsibility) along with the revised CARC 1 and/or 2 with the monetary amounts. The RAs will also include revised RARCs N781 and N782.

See the QMB Program webpage for more information.

Advance Beneficiary Notice of Noncoverage (ABN) for QMB Beneficiaries

There is special guidance on the ABN instructions for people who are dually enrolled in both Medicare and Medicaid, also known as dually eligible individuals (who have a Qualified Medicare Beneficiary (QMB) Program and/or Medicaid coverage) only:

Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication. Strike through all of Option Box 1 as provided below:

OPTION 1. I want the (D) listed above. I want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN).

These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries. If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:

  • If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
  • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary liability.

Note: These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances. More information on dual eligible beneficiaries may be found in the CMS Dually Eligible Beneficiaries Under Medicare and Medicaid booklet

Verifying Eligibility for QMB Beneficiary in the Noridian Medicare Portal (NMP)

This NMP inquiry allows users to view a beneficiary's Medicare eligibility including indicating if a beneficiary is enrolled as a QMB beneficiary.

If the beneficiary is enrolled as a Qualified Medicare Beneficiary (QMB), a green banner will display letting the user know that the beneficiary is a QMB enrollee for one or more Part B Benefit Periods.

In addition to the QMB banner, there is a "QMB Enrolled" indicator which will indicate "Yes" or "No" if the patient is a QMB enrollee for the Part B Benefit period.

QMBs are not liable for Medicare deductibles, therefore deductible information for QMBs is not provided in NMP. This prevents patient status errors, incorrect billing and financial records. Noridian recommends contacting the patients state Medicaid agency for questions about deductible billing.

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Last Updated Nov 01 , 2024