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Qualified Medicare Beneficiary (QMB) Program

11/14/2017 - QMB Remittance Advice Issue:

QMB Remittance Advice Issue

On October 2, 2017 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, 2017 CMS systems will revert back to the previous display of patient responsibility for QMBs on RAs. Providers may want to hold QMB claims and submit them after December 8.

Providers: see here for more information.

Recent Posts:

08/25/17 - Registration information for the Qualified Medicare Beneficiary (QMB) Program Billing Rules Call posted.

Qualified Medicare Beneficiary (QMB) Program Billing Rules Call (September 19, 2017): Registration

What is the Qualified Medicare Beneficiary (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 2015, 7.2 million people (more than 1 out of every 10 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.

Information for Medicare Providers & Suppliers

Information for Medicare Advantage Plans

Information to Share with People with Medicare & their Advocates

Information for States

Additional Resources