Due to the very low reimbursement rates, many providers decline to enroll in Medicaid, and therefore charge any Medicaid patients cash for services provided, if the state allows this practice.  A much larger percentage of providers have remained opted-in to Medicare, however.  Since 21% of all Medicare recipients are "Dually Eligible" - are entitled to enrollment in both Medicare and Medicaid - in any congregation of office managers, practice managers, and billers, the following question often pops up:

"Can a dually eligible patient be balance billed when the provier is not a Medicaid provider?" The answers offered up will vary, but will almost always fall into one of the following categories:

  • Yes
  • Yes, but you must get a waiver from the patient first
  • Yes, with a signed Advance Beneficiary Notice
  • It depends on what state you're in 

Would it shock you to learn that for a specific class of dually eligible, all the above answers are wrong?

Whether or not the provider is enrolled in Medicaid, every Medicare provider's front office and billing staff needs to be very familiar with the term "QMB". QMB is "Qualifed Medicare Beneficiary".  A patient who is a QMB has a state Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to state payment limits.  Therefore, Medicare providers are required to accept the Medicaid payment in full, even if the state ends up paying zero and even if the provider doesn't or can't bill Medicaid.. The only amounts billable are Medicaid nominal copays, if the state requires it. Violations may result in sanctions.

This is a Medicare rule, not a Medicaid rule.

"But we don't take Medicaid.  We are not even enrolled. We cannot get Medicaid payment."  It doesn't matter. This is required by federal law and every Medicare provider agreement; therefore, every Medicare provider must comply, whether or not they are even able to bill Medicaid.  An Informational Bulletin, issued in 2012 by CMS’ Medicare-Medicaid Coordination Office to the State Medicaid Agencies, said this: “Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments.” See also MLN Matters® Number: SE1128 for confirmation and more information. Also, be aware you cannot simply accept the patient as a "cash pay" patient to bypass the balance-billing prohibition.

Important exceptions are if you are an opt-out provider, or if the patient is enrolled in a Medicare Advantage plan for which you are not a contracted provider.

So, what is the action plan to ensure you are never sanctioned for balance billing a QMB patient?

  1. Immediately inspect all Medicare patient accounts and determine if patient refunds need to be made.
  2. See if your state allows "cross-over only" Medicaid provider enrollment.  This allows you to receive payment (if fee schedules allow) for all dually eligible patients without obligating you to accept regular Medicaid.
  3. If you still choose not to enroll in Medicaid or your state does not have cross-over only enrollment, contact your state to learn how a non-enrolled provider can get eligibility information for determining QMB status.  Be aware that Medicare Advantage plans are required to make this information available for all its enrolled members. You can also require patients to show their Medicaid ID cards along with their Medicare ID cards.  Just rmember, it is the provider's responsibility to determine QMB status.
  4. Make sure your billing software is set to prevent statements from going out to QMB patients.

As you speak with your state Medicaid agency, be aware that there are two classes of QMB individuals, and different states give them different names.  CMS and most states refer to them as QMB and QMB+, but other states use different terminology - for instance, Texas uses QMB and MQMB.  Ask your state what specific terms you need to be looking for to properly identifiy all QMB classes on the state Medicaid card or eligibility check.

Make a plan today to get your staff instructed on the rules and ways to obtain proper QMB status to avoid sanctions!



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