Getting Started: What SHIPs Need to Know
Qualified Medicare Beneficiaries (QMB) and Medicare Cost-Sharing
Can a health care provider or an MA plan bill QMBs for Medicare cost-sharing?
No. According to Title 42 of the United States Code, section 1396a (n), neither providers nor Medicare Advantage (MA) plans can bill QMBs for Medicare cost-sharing. Providers are not allowed to balance bill QMBs for any Original Medicare deductibles or coinsurance charges; they also cannot bill for MA plan cost-sharing for office visits, referrals to specialists, or Durable Medical Equipment (DME). QMBs are not liable under Medicare law to pay providers for any of these charges.
Can QMBs be reimbursed for these costs if their provider incorrectly billed them?
Yes. QMBs in Original Medicare can follow up with their state Medicaid office or directly with their provider to request a reimbursement.
QMBs who are billed by their MA plan providers (even those who are not "set up" to bill Medicaid) can file grievances with their plans. Plans should have a billing procedure for QMBs, regardless of the plans’ contract status with the state. Under ideal circumstances, MA plans should refund these copayments to the QMB (or have the provider reimburse the QMB), and the plans should also advise the provider to bill Medicaid for future copayments.
What is the follow-up process for QMBs whose provider or MA plan does not provide a reimbursement?
If a QMB has presented sufficient identification (e.g., a QMB card, letter of approval) verifying QMB status and a provider continues to deny the request for reimbursement, the beneficiary can report the issue to the local Medicaid office or 1-800-MEDICARE.
Are there any other resources for SHIPs to help QMBs get reimbursements?
HAP offers a sample letter to providers as an additional resource that SHIPs can customize and use to help QMB clients obtain reimbursements from providers.
Where can I share examples of this issue happening in my state?
As part of HAP's Troubleshooting Medicare project to identify the persistent and systemic issues facing beneficiaries across the Medicare program, we have developed a web-based Issue Log to help SHIPs share their experiences. The feedback SHIPs submit to the Issue Log will be used to develop trainings for the SHIP network, and also will inform recommendations to policy makers on how to address the issues. To access the Issue Log, contact us at SHIPhelp@hapnetwork.org with your name, state, organization, and current SHIP role. HAP will provide you with a username and password so you can start logging issues.
