Per MLN Matters SE1128 release date 05/12/17, federal law bars Medicare providers from billing a QMB beneficiary under any circumstances. See Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by Section 4714 of the Balanced Budget Act of 1997. QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance, and copayments. However, as permitted by federal law, states can limit provider reimbursement for Medicare cost-sharing under certain circumstances. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.
Important clarifications concerning the QMB billing law is as follows:
- All original Medicare and MA providers – not only those that accept Medicaid – must abide by the billing prohibitions.
- QMB individuals retain their protection from billing when they cross state lines to receive care. Providers cannot charge QMB individuals even if the patient’s QMB benefit is provided by a different state than the state in which care is rendered.
- Note that QMBs cannot choose to “waive” their QMB status and pay Medicare cost-sharing. The federal statute referenced above supersedes Section 3490.14 of the State Medicaid Manual, which is no longer in effect.