News & Press: Advocacy

Important Reminder About Medicare Billing Requirements for Certain Dual-Eligibles

Monday, July 18, 2016  
Share |
The American Medical Association has issued a reminder for U.S. physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries—individuals who are enrolled in both Medicare and Medicaid—with Medicare cost-sharing. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers—even those who do not accept Medicaid—from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.  

For further information, see MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.

Contact Us

120 E. Ogden Ave. Ste. 202
Hinsdale, Illinois 60521
P: 630.203.2252
Toll Free: 888.255.0005

© Copyright 2016 Spine Intervention Society Privacy Policy  ::  Legal