Subscribe

Dual-Eligible Beneficiaries: What to Do When Medicaid Does Not Pay

Rheumatology Practice Management October 2018 Vol 6 No 5 - Coding Corner
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
President and Senior Consultant
Acevedo Consulting
Delray Beach, FL

 

The Centers for Medicare & Medicaid Services (CMS) has published numerous articles notifying Medicare providers and suppliers that they cannot bill beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program for Medicare cost-sharing. QMBs have Medicare as their primary insurance and Medicaid as their secondary insurance. Medicare beneficiaries enrolled in the QMB program are not legally obligated to pay the deductibles, coinsurance, or copays for any Medicare-covered items or services. In addition, a state may or may not pay the deductible or coinsurance for the QMBs it insures, depending on its Medicaid program; most states do not.

CMS reports that, despite federal law, providers continue to improperly bill individuals enrolled in the QMB program. Many beneficiaries are unaware of the billing restrictions (or are concerned about undermining their relationship with their physician) and simply pay the cost-sharing amounts. Medicare providers that attempt to collect the deductible or coinsurance from a QMB are violating their Medicare provider agreement and can face serious sanctions.

There are no exceptions. Any deductible or coinsurance amounts not paid by a Medicaid secondary plan for a QMB patient must be written off. The following are some points to keep in mind:

  • If the QMB has a Medicaid HMO/Managed Care plan secondary to Medicare, do not bill the patient for any unpaid deductible or coinsurance that Medicaid does not pay.
  • If the QMB has traditional Medicare and you are not a Medicaid provider, do not bill the patient for any unpaid deductible or coinsurance that Medicaid does not pay.
  • If the QMB has a Medicare Advantage plan as primary insurance with traditional Medicaid or a Medicaid Managed Care plan as secondary insurance, do not bill the patient for any unpaid deductible or coinsurance.

Those who qualify as a QMB must meet certain income levels based on the federal poverty level (FPL). For 2018, the monthly income limit is 100% of the FPL + $20. When you consider this income requirement, it is fairly easy to understand why the federal government does not allow these beneficiaries to be held personally responsible for the Medicare deductible or 20% coinsurance.

Please be aware of the following policy clarifications pertaining to QMB billing requirements:

  • All original Medicare and Medicaid Advantage providers and suppliers—not only those that accept Medicaid—must not charge individuals enrolled in the QMB program for Medicare cost-sharing.
  • Individuals enrolled in the QMB program retain their protection from billing when they cross state lines to receive care. Providers and suppliers cannot charge individuals enrolled in QMB even if their QMB benefit is from a state other than the one where they receive care.
  • Individuals enrolled in QMB cannot elect to pay Medicare deductibles, coinsurance, and copays, but may have a small Medicaid copay.
Related Items
Medical Necessity: Documenting What the Payer Wants
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management August 2018 Vol 6 No 4 published on September 5, 2018 in Billing Update
Update on the 1995 and 1997 Evaluation and Management Documentation Guidelines
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management June 2018 Vol 6 No 3 published on June 20, 2018 in Coding Corner
To Bill or Not to Bill: an Infusion Case Study
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management April 2018 Vol 6 No 2 published on April 16, 2018 in Coding Corner
“Incident to” Billing and Nonphysician Practitioners
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management February 2018 Vol 6 No 1 published on February 16, 2018 in Billing Update
“Nurse Visits” and Current Procedural Terminology Code 99211
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management December 2017 Vol 5 No 6 published on January 8, 2018 in Coding Corner
Are the 1995 and 1997 Evaluation and Management Documentation Guidelines on Their Way Out?
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management October 2017 Vol 5 No 5 published on October 20, 2017 in Billing Update
New Biosimilar Modifier for Q5102
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management October 2017 Vol 5 No 5 published on October 20, 2017 in Coding Corner
That Infamous Evaluation and Management Code 99214
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Rheumatology Practice Management August 2017 Vol 5 No 4 published on August 16, 2017 in Coding Corner
“Incident to” Services
Candice Fenildo, CHC, CPC, CPMA, CPB, CPC-1, CRHC, AAPC Fellow
Rheumatology Practice Management June 2017 Vol 5 No 3 published on June 28, 2017 in Coding Corner
Last modified: November 2, 2018
  • American Health and Drug Benefits
  • Lynx CME
  • Value Based Care in Rheumatology
  • Oncology Practice Management
  • Urology Practice Management

Search