Qualified Medicare Beneficiary (QMB) Program Group

The QMB group provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries (QMBs). In 2023, more than 8 million individuals (more than 1 out of 8 Medicare beneficiaries) were in the QMB group.

Provider Enrollment and Third Party Liability for Items and Services Rendered to Dually Eligible Individuals 

The Provider Enrollment and Third Party Liability for Services Rendered to Dually Eligible Individuals Frequently Asked Questions (FAQs) (01/14/2025) (PDF) address provider enrollment in Medicare or Medicaid and how it impacts: billing for services provided to dually eligible individuals; QMB billing protections; coordination of benefits; and third party liability. 

Billing Protections for QMBs

Federal law prohibits Medicare providers and suppliers, including pharmacies, from billing individuals in the QMB group for Medicare cost sharing. Medicare beneficiaries enrolled in the QMB group have no legal obligation to pay Part A or Part B deductibles, coinsurance, or copayments for any Medicare-covered items and services.

Despite the federal law, our July 2015 study found that those in the QMB group are still wrongly billed and confusion around billing rules continues. We have taken several steps since to help Medicare providers and beneficiaries better understand the QMB protections. Please view the resources below. 

Information for Medicare Providers & Suppliers

• Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program (PDF) (revised 10/2024)
• Reminder of Prohibition on Billing QMBs & Resources Available to Identify QMB Status (PDF) (revised 10/31/2024)
• Beneficiaries Dually Eligible for Medicare & Medicaid (PDF)
• Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of QMBs for Medicare Cost-Sharing
• QMB Program FAQ on Billing Requirements (PDF)
• Checking Medicare Eligibility (PDF)
• MM10433 (PDF): Reinstating the QMB indicator in the Medicare Fee-for-Service Claims Processing System from CR9911
• MM11230 (PDF): Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the QMB Group

Information for Medicare Advantage Plans

• CY 2024 Part C & Part D Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, Medicare-Medicaid Plans, and Cost Plans (PDF) (10/13/2023)
• Qualified Medicare Beneficiary Group Information in Remittance Advice & Explanation of Benefits (4/3/2018) (PDF) 
• Preventing Improper Billing of Medicare-Medicaid Enrollees in Managed Care: Strategies for States and Dual Eligible Special Needs Plans

Information for Medicare Beneficiaries & their Advocates

• 3 Tips for People in the QMB Program (English & Spanish (PDF))
• Seniors & Medicare and Medicaid Enrollees
• Medicare Savings Programs
• Medicare-Medicaid Enrollee Categories (PDF)

Information for States

• Medicaid Third Party Liability & Coordination of Benefits
• Payment of Medicare Cost Sharing for QMBs
• Billing for Services Provided to QMBs
• Medicare Competitive Bidding Program for Durable Medical Equipment and Coordination of Benefits for Beneficiaries Eligible for Medicare and Medicaid (Dual Eligibles)
• Preventing Improper Billing of Medicare-Medicaid Enrollees in Managed Care: Strategies for States and Dual Eligible Special Needs Plans

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