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Qualified Medicare Beneficiary (QMB) Program

08/06/2018 - QMB Program Billing Requirements Call (06/06/2018) Event Materials & Recording (including FAQs, presentation slides, audio recording, & transcript)

06/01/2018 - Qualified Medicare Beneficiary Program Information in Remittance Advice and Explanation of Benefits (4/3/2018)

2018 Part C & Part D Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, and Cost Plans (10/26/2017)

Qualified Medicare Beneficiary Program Enrollee Status Resources (6/21/2017)

QMB Program Billing Requirements Call - Wednesday, June 6, 2018 (Event Materials & Recording)

On June 6, 2018, the CMS Medicare Learning Network (MLN) hosted a call to discuss the QMB billing requirements.

During this call, CMS experts discussed the QMB billing requirements and their implications, including the July 2018 re-launch of changes to the remittance advice and November 2017 changes to the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) used to identify the QMB status of your patients and exemption from cost-sharing. Participants also learned key steps to promote compliance. Target audience: Medicare Part A and B providers, medical billing specialists, practice administrators, and other interested stakeholders.

QMB Claims: Replacement Remittance Advices (RAs)

Medicare Administrative Contractors (MACs) will issue replacement RAs through non-monetary mass adjustments for QMB claims paid after October 2, 2017 and up to December 31, 2017, that have not been voided or replaced. Use the replacement RAs to resubmit Medicaid QMB cost-sharing claims that states initially failed to pay due to the RA changes. To avoid duplicate claims, do not resubmit claims that were successfully processed by secondary payers through claims submission or the Coordination of Benefits Agreement process.

For more information, please see MLN Matters® Article MM10494 (Adjustments to QMB Claims Processed Under CR 9911).


What is the QMB Program?

People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. In 2016, 7.5 million people (more than one out of eight people with Medicare) were in the QMB program.


What are the Billing Requirements Affecting People in the QMB Program?

Medicare providers and suppliers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Under some circumstances, federal law lets states limit how much they pay providers for Medicare cost-sharing. Even when that's the case, people in the QMB program have no legal obligation to pay Medicare providers for Medicare Part A or Part B cost-sharing.

Despite these billing rules, our July 2015 study ("Access to Care Issues Among QMBs") found that those in the QMB program are still being wrongly billed and that confusion about billing rules continues. We're sharing this information to help you understand the QMB program and its billing rules.


Timeline of CMS Changes for QMB RAs & the MSNs

  • October 2, 2017: RAs began identifying the QMB status of beneficiaries & reflecting their zero cost-sharing liability (MM9911 & QMB RA Issue)
  • December 8, 2017: CMS temporarily suspended the system changes due to unforeseen issues affecting the processing of QMB cost-sharing claims by states & other payers secondary to Medicare
  • March, 2018: MACs begin issuing replacement RAs for claims paid after October 2, 2017 and up to December 31, 2017, that have not been voided or replaced (by December 20, 2018 for Part B, and by September 20, 2018 for Part A & DME, MAC claims). (MM10494)
  • July, 2018: CMS will reintroduce QMB information in the RA without disrupting claims processed by secondary payers (MM10433)


Additional Information for Medicare Providers & Suppliers


Additional Information for Medicare Advantage Plans


Additional Information to Share with People with Medicare & their Advocates


Additional Information for States


Additional Resources