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 July 1, 2018, CMS will reintroduce QMB information on Medicare Remittance Advices (RAs) per CMS Change Request (CR)10433. This will reinstate 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. The revised RARCs are as follows:
- 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.
On October 2, Change Request 9911 modified the Medicare Remittance Advice (RA) for Qualified Medicare Beneficiary (QMB) claims to identify QMB patients and reflect zero cost-sharing liability. This change resulted in unanticipated issues for providers, states, and other secondary payers who are used to seeing Medicare deductible and coinsurance amounts in specific fields on the RA. Beginning December 8, CMS systems will revert back to the previous display of patient responsibility for QMBs on RAs. You may want to hold QMB claims and submit them after December 8. See the QMB Program webpage for more information.
Beginning October 2, 2017, messages will appear on the provider's remittance advice to reflect a beneficiary's QMB status with one of the following remittance advice remark codes (RARCs).
- N781 - No deductible may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
- N782 - No coinsurance may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
- N783 - No co-payment may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
The claim adjustment reason code (CARC) on these claims shows as:
- OA-209 - Per regulatory or other agreement. The provider cannot collect this amount from the patient.
- CMS Dual Eligible Beneficiaries Under Medicare and Medicaid Booklet
- CMS Medicare Learning Network (MLN) Matters Special Edition (SE)1128
- CMS MLN Matters (MM)9911
Last Updated Jan 27, 2020