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Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program (one of the Medicare Savings Programs) are not required to pay Medicare cost-sharing, such as Medicare Parts A and B deductibles. In fact, federal law does not allow providers to charge Medicare cost-sharing for people with QMB.

However, billing issues do happen. Most state Medicaid agencies do not make cost-sharing payments to providers on behalf of QMBs because of something called “lesser of” policies. Lesser of policies allow states to limit their payment to the “lesser of” the Medicare deductible and coinsurance, or the Medicaid reimbursement rate. Lesser of policies often mean that physicians receive little or no Medicare cost-sharing reimbursement. Thus, despite the federal prohibition, some providers inappropriately bill and collect the Medicare cost-sharing from people who qualify for QMB, creating financial burden and stress for these beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) is committed to mitigating this problem through outreach to beneficiaries and providers. Recent CMS efforts include:

  • In the Medicare & You 2017 handbook, mailed to beneficiaries in September, CMS included additional information about QMB billing, to ensure QMBs understand they are not required to pay for Medicare cost-sharing.
  • Beginning Sept. 19, 2016, Beneficiary Contact Center representatives at 1-800-MEDICARE were instructed by CMS to start identifying a caller’s QMB status, and then to advise the caller on QMB billing protections.
  • Effective Dec. 6, 2016, Medicare Administrative Contractors (MACs) will begin accepting referrals regarding beneficiary complaints about QMB billing problems from Beneficiary Contact Center representatives. MACs are then required to send compliance letters to providers and suppliers, and send a copy of the letter to the named beneficiary with an explanatory cover letter. The letter to providers and suppliers instructs them to refund any improperly collected funds to the beneficiary, and to review past records for other cases of inappropriate billing of QMBs. MACs will be required to send these materials within 45 days of receiving the referral.
  • CMS published an MLN Matters article to inform providers about the new compliance letters that will be sent regarding the inappropriate billing of QMBs for Medicare cost-sharing. A copy of the MLN Matters article and the CMS Transmittal on the issue can be found here.