Medicare Plus Blue will begin reporting qualified Medicare beneficiaries’ eligibility on applicable claim lines

Certain billing prohibitions apply to dual-eligible beneficiaries who meet the requirements for the Qualified Medicare Beneficiary program. As a result, Medicare now flags remittance advices for these beneficiaries because their cost sharing for deductibles, copayments and coinsurance is zero.

All Medicare and Medicaid payments received for furnishing services to a QMB are considered payment in full, even if Medicaid covers nothing. Providers must refund any money collected from a QMB for cost sharing, or recall any bills sent to a QMB or turned over to collections for these charges. Providers may bill subsequent payers for said cost-sharing amounts.

Medicare Plus Blue^SM wants to assist providers with not allowing QMB members to be charged for cost sharing applicable to services that fall within QMB eligibility. That’s why Medicare Plus Blue will adapt the Centers for Medicare & Medicaid Services’ standards of reporting members’ QMB eligibility on applicable claim lines.

When a claim comes in for an active QMB member (Dual Status Code 01 or 02), a new event code mapped to the CMS-recommended claims adjustment group code, claims adjustment reason code or remittance advice remark code combination will be applied to the claim line. Where the claim will be mapped will depend on whether the member pays a deductible, coinsurance, copayment, blood deductible, or deductible or coinsurance for professional services received in an institutional setting.

It will also be displayed on the provider explanation of payment or electronic 835 as well as the member’s explanation of benefits.

Background

• QMB program — Helps pay premiums, deductibles, coinsurance and copayments for Part A, Part B, or both programs
• Specified Low-Income Medicare Beneficiary Program — Helps pay Part B premiums
• Qualifying Individual Program — Helps pay Part B premiums
• Qualified Disabled Working Individual Program — Pays the Part A premium for certain disabled and working beneficiaries

Dual-eligible beneficiaries include those who are enrolled in Medicare Part A or Part B, and receiving full Medicaid benefits or assistance with Medicare premiums or cost sharing. The beneficiaries are receiving benefits or assistance through one of these Medicare Savings Program categories:

Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of the Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMBs for all Medicare deductibles, coinsurance or copayments.

Providers are subject to sanctions if they bill a QMB for amounts above the total of all Medicare and Medicaid payments (even when Medicaid pays nothing). For more information on prohibited billing of QMBs, see Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program** and Section 1902 of the Act.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.