Understanding Medicaid’s Qualified Medicare Beneficiary Program

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Medicaid’s Qualified Medicare Beneficiary (QMB) program assists low-income beneficiaries with Medicare premiums, deductibles, coinsurance, and Medicare Advantage Plan co-pays. Often referred to as “dual eligible beneficiaries,” these individuals are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums, or cost sharing through one of four “Medicare Savings Programs” (MSP):

  • Qualified Medicare Beneficiary (QMB) Program
    Helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments.
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
    Helps pay for Part B premiums.
  • Qualifying Individual (QI) Program
    Helps pay for Part B premiums.
  • Qualified Disabled Working Individual (QDWI) Program
    Pays the Part A premium for certain people who have disabilities and are working.

Who Does QMB Impact?

Physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

How Are HME Suppliers Impacted?

How Can DME Suppliers Identify QMB Recipients?

Currently, neither the Medicare eligibility systems (HIPAA Eligibility Transaction System) nor the claims processing systems (the FFS Shared Systems) notify providers and suppliers about their patient’s QMB status and lack of Medicare cost-sharing liability. Likewise, Medicare Summary Notices (MSNs) do not inform those enrolled in the QMB program that they do not owe Medicare cost-sharing for covered medical items and services. However, providers and suppliers can expect changes to this process with the implementation of CMS Change Request (CR) 9911. 

Change Request (CR) 9911 includes modifications to the FFS claims processing systems and the “Medicare Claims Processing Manual” to generate notifications to Medicare providers and beneficiaries regarding beneficiary QMB status and lack of liability for cost-sharing.

With the implementation of CR 9911, Medicare’s Common Working File (CWF) will provide the claims processing systems with the following QMB indicators (RARC & CARC) if the dates of service coincide with a QMB coverage period for claims processed on or after October 2, 2017:

Remittance Advice Remark Codes (RARCs)

  • N781 No deductible may be collected as a 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 a patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
  • N783 No copayment may be collected as a patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.

Claim Adjustment Reason Code (CARC)

  • OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected.

Notification to QMB recipients

Beneficiaries will be notified through their Medicare Summary Notice (MSN).

 QMB Violations

  • Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions, as described in Sections 1902(n)(3); 1905(p); 1866(a)(1)(A); and 1848(g)(3) of the Social Security Act (the Act).
  • All Medicare beneficiaries received “Medicare & You 2017,” which contains new language to advise QMB individuals about their billing protections.
  • MACs will issue a compliance letter for all inquiries referred. This compliance letter will instruct named providers and suppliers to refund any erroneous charges and recall any past or existing QMB billing (including referrals to collection agencies).
  • MACs will also send a copy of the compliance letter to the named beneficiary, with a cover letter advising the beneficiary to show the mailing to the named provider and verify that the provider corrected the billing problem.
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