Posted Jan. 6, 2021
As a provider treating Blue Cross Medicare AdvantageSM members, you may not bill beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) Program, a federal Medicare Savings Program. Members enrolled in QMB are dual eligible beneficiaries, which means they are eligible for both Medicare and Medicaid. As a State Medicaid benefit, QMB covers these members’ Medicare Advantage premiums, deductibles, coinsurance and copayments. QMB members are not responsible for Medicare Advantage cost-sharing, or out-of-pocket costs.
For services you provide to QMB patients, you must:
- Bill both Medicare Advantage and Medicaid
- Accept Medicare Advantage payments and any Medicaid payments as payment in full
Tips to avoid billing QMB patients
Please ensure that you and your staff are aware of the federal billing law and policies governing QMB. It is against federal law for any Medicare provider to bill QMB patients, whether the provider accepts Medicaid. Per your Medicare Provider Agreement, you may be sanctioned if you inappropriately bill QMB members for Medicare Advantage cost-sharing.
To avoid billing QMB patients, please take these precautions:
- Understand the Medicare Advantage cost-sharing billing process
- Be sure your billing software and staff remove QMB members from Medicare Advantage cost-sharing billing and related collections efforts
Call Customer Service at 877-774-8592 to learn more about QMB procedures and ways to identify QMB patients. For more details about QMB, see the Centers for Medicare & Medicaid Services website.
This is a brief description of some of the terms of the Medicare Advantage plans. For more details, please refer to the applicable Medicare Advantage document. The information provided here is only intended to be a summary of the law that have been enacted and is not intended to be an exhaustive description of the law or a legal opinion of such law. If you have any questions regarding the law mentioned here, you should consult with your legal advisor.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.