CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prohibition on Billing Qualified Medicare Beneficiaries (QMBs)

Governs prohibition on billing Medicare Part A and B cost-sharing to beneficiaries in the Qualified Medicare Beneficiary (QMB) eligibility group; applies to all Original Medicare and Medicare Advantage providers and suppliers interacting with QMBs.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProhibition on Billing Qualified Medicare Beneficiaries (QMBs)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill QMBs for Medicare Part A/B cost-sharing; if billed, recall bills and refund collected amounts and bill the state Medicaid program for cost-sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AllProviders/suppliers prohibited

QMBCoverage scope

EnrollState requirement

RefundProvider remediation

Prohibition on Billing QMB Cost-Sharing

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProhibition on Billing Qualified Medicare Beneficiaries (QMBs)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill QMBs for Medicare Part A/B cost-sharing; if billed, recall bills and refund collected amounts and bill the state Medicaid program for cost-sharing.

SourceLink

On This Page

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Federal prohibition: Do not bill Qualified Medicare Beneficiaries (QMBs) for Medicare Part A or Part B cost-sharing for any date of service on which the individual is a QMB; billing QMBs violates Medicare provider obligations and may subject providers or suppliers to sanctions.

ALL of the following

If a QMB was improperly billed, recall any bills for Medicare cost-sharing or bills turned over to collections for that QMB.
Refund any collected Medicare cost-sharing amounts to the QMB.

ALL of the following

State billing pathways: Providers and suppliers may bill state Medicaid programs for Medicare cost-sharing; many states and Medicaid managed care plans use an electronic crossover process to receive Medicare-adjudicated claims for QMB cost-sharing payment (crossover noted on the Medicare RA).
States must provide a means for Medicare providers and suppliers to enroll in the Medicaid program for the purpose of processing QMB claims for state payment of Medicare cost-sharing, even if a provider or service category is not otherwise recognized in the Medicaid State Plan; contact the State Medicaid Agency for enrollment procedures.

ALL of the following

Before claiming Medicare bad debt for unpaid Medicare deductible, coinsurance, or copayment amounts, bill the state to determine the state's liability and receive a Medicaid remittance advice (RA) showing the state's determination.
Follow 42 CFR 413.89 and relevant Provider Reimbursement Manual guidance when seeking Medicare bad debt treatment.

Ensure compliance: identity verification

Verify QMB status prior to billing using available resources such as HETS 270/271 responses, MAC online portals or IVR systems, automated state Medicaid eligibility-verification systems, Medicare RAs and MSNs, pharmacy E1 transactions, or other QMB documentation (Medicaid ID, MSN).
If an MA provider, contact the MA plan for the preferred method to identify QMB status for plan members before and after claims submission.

Do not accept a QMB's election to pay Medicare cost-sharing; QMBs may not be charged or elect to pay deductibles, coinsurance, or copayments even if their QMB benefit comes from a different state.

Billing Pathways, Bad Debt, and Code Guidance

Billing pathways and bad debtmixed

States may process Medicare cost-sharing via electronic crossover; providers may claim Medicare bad debt per 42 CFR 413.89 after billing state and receiving Medicaid RA.

Medicare bad debt prerequisite

Prerequisite for claiming Medicare bad debtProviders must bill the state Medicaid program and receive a Medicaid remittance advice (RA) before claiming unpaid Medicare deductible, coinsurance, or copayment as Medicare bad debt (see 42 CFR 413.89).

Regulatory referenceSee 42 CFR 413.89 and chapter 3 of the Provider Reimbursement Manual Part 1 for detailed Medicare bad debt rules.

State billing requirementProviders must bill the state to determine the state's Medicare cost-sharing liability prior to claiming bad debt.

Scope of amountsApplies to unpaid Medicare Part A and Part B deductible, coinsurance, and copayment amounts that a provider may consider for bad debt treatment.

Provider Billing and Remediation Requirements

Billing Rule

Do not bill QMBs; recall/refund improper charges and bill State Medicaid

Do not bill QMBs for Medicare Part A or Part B cost-sharing. If QMBs were improperly billed, recall those bills (including bills sent to collections), refund any collected cost-sharing amounts to the QMB, and follow state procedures to bill the Medicaid program for Medicare cost-sharing payments. Enroll with the State Medicaid Agency as needed to submit QMB claims for state payment and obtain a Medicaid remittance advice before pursuing Medicare bad debt.

Federal law prohibits Original Medicare and Medicare Advantage providers and suppliers from billing QMBs for Part A/B cost-sharing (deductibles, coinsurance, copayments).
Recall any bills for QMB Medicare cost-sharing or bills turned over to collections and refund any collected amounts to the QMB.
Determine and follow the state’s process to bill Medicaid for Medicare cost-sharing; states must allow enrollment of Medicare-enrolled providers for this purpose and many states use an electronic crossover process.
Bill the state and receive a Medicaid remittance advice (RA) before claiming Medicare bad debt per 42 CFR 413.89.

Key Definitions

Qualified Medicare Beneficiary (QMB) — eligibility and coverage scope

DefinitionQualified Medicare Beneficiary (QMB) is a Medicaid eligibility group that covers Medicare Part A and Part B deductibles, coinsurance, and copayments for certain low‑income Medicare beneficiaries.

Billing prohibitionFederal law prohibits all Original Medicare and Medicare Advantage providers and suppliers from billing QMBs for Medicare Part A and Part B cost‑sharing.

Provider obligationsProviders must implement processes to identify QMB status and ensure QMBs are not billed; if improper billing occurs, providers must take action to remedy billing and collections.

State payment pathwayProviders may bill state Medicaid programs for Medicare cost‑sharing; states must provide a means for providers to enroll to process QMB claims (see 42 CFR 455.410(d)).