1. Schaum, Kathleen D. MS

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Over the past month, I have received numerous questions about the Qualified Medicare Beneficiary (QMB) program. To make the QMB program come alive, let's begin with a true-to-life story about my 95-year-old neighbor, whom I will refer to as Bob. For 50 years, Bob worked full time and contributed to the Social Security program and to Medicare Part A. When Bob retired, he opted to purchase Medicare Part B and the Medicare Part D drug benefit. Therefore, he incurred the costs for the monthly Part B and Part D premiums, as well as any Part A coinsurance, Part B deductibles and 20% coinsurance, and Part D copayments for drugs.


Unfortunately, Bob's wife had many debilitating health problems, which required renovations to their small home, paid caregivers, multiple drugs not covered by their drug plan, skilled nursing facility care for nearly 10 years, and so on. Bob never denied care to his wife. If insurance did not pay for something she needed, Bob took the money out of their savings. By the time Bob's wife died, he had depleted most of his savings and had developed major health issues that continued to drain his finances.


One day I learned that Bob was running out of money. Because Bob was already enrolled in Medicare Part A and Part B, I thought he might qualify for one of his state's Medicaid programs. Bob shared that his monthly income was less than $1001 per month, and his resources were less than $7280-the threshold for applying to his state's QMB Program. Note: Countable resources for the QMB program include money in a checking or savings account, stocks, and bonds. Countable resources do not include home, 1 car, burial plot, up to $1500 for burial costs (if money was put away for that purpose), furniture, or other household and personal items.


Bob applied and qualified for the QMB Program, which now pays his Medicare Part B premium and his Medicare deductibles, coinsurance, and copayments-to the extent required by the State Medicaid Plan. He received a special insurance card that shows he is in the QMB program. I helped Bob inform all of his medical professionals and medical facilities about his new insurance. All of the medical offices and medical facilities photocopied Bob's QMB insurance card and said that his medical record would show that he is "dually eligible" because he is now enrolled in both Medicare and Medicaid.


Shortly after becoming "dually eligible," Bob received care from several of his physicians. After Medicare paid its portion of the bill, every one of the physicians' offices billed Bob for the coinsurance that they should have billed to Medicaid. Bob and I contacted the offices to tell them they made a billing mistake and should have billed Medicaid. For several more months, Bob continued to receive coinsurance bills from all of the offices. He and I contacted each office every time he received another bill that should have been sent to Medicaid.


Then the unthinkable happened: Bob received collection agency notices pertaining to every one of those bills. When Bob contacted the offices, they told Bob that he was responsible for the coinsurances because his state's Medicaid rates for the services Bob received were less than the Medicare allowable rates. Because Bob was afraid that the physicians would no longer provide care to him and that going to collection would be a "black mark" on his credit rating, he told me he was going to pay all the bills. At that point, I provided Bob and all the physicians' offices with the regulation about the prohibition on balance billing "dually eligible" individuals enrolled in the QMB program. It was amazing how quickly they contacted the collection agencies and rescinded their collection requests! It was also amazing that Bob never received another bill from these offices.


You may be asking yourself: "Why did Kathleen share Bob's story with us?" The answer is simple. Many medical professionals, including wound care professionals, do not seem to be aware of the QMB program billing rules. So let's quickly review the Medicare and Medicaid programs to learn where the QMB program fits.



Medicare is health insurance for people 65 years or older, certain people younger than 65 years with disabilities, and people of any age with end-stage renal disease. Medicare consists of Part A, Part B, Part C, and Part D. Medicare beneficiaries can obtain their Medicare coverage in the following ways:


* receive Part A and Part B services through the Original Medicare Program; to obtain Part D coverage, they must join a stand-alone Prescription Drug Plan; or


* receive Part A and Part B services from a Medicare Advantage Plan if they reside in its service area. Most Medicare Advantage plans include Part D coverage.




The Medicaid Program is a cooperative venture funded by federal and state governments that pay for medical costs for certain individuals and families with low incomes and, in some cases, limited resources. Within broad national guidelines established by federal statutes, regulations, and policies, each state


* establishes its own eligibility standards;


* determines the type, amount, duration, and scope of services;


* sets the rate of payment for services; and


* administers its own program.




"Dual-eligible beneficiaries" is the general term that describes individuals who are enrolled in both Medicare and Medicaid. The term includes individuals who are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through one of the following "Medicare Savings Program" (MSP) categories:


* Qualified Medicare Beneficiary Program helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments.


* Specified Low-Income Medicare Beneficiary Program helps pay for Part B premiums.


* Qualifying Individual Program helps pay for Part B premiums.


* Qualified Disabled Working Individual Program pays the Part A premium for certain people who have disabilities and are working.



The options for "dual-eligible" individuals to receive their Medicare and Medicaid benefits vary by state. In some states, dual-eligible individuals receive Medicaid through Medicaid managed care plans, and in other states, Medicaid coverage may be fee-for-service. In some states, certain dual-eligible individuals can join plans that include all Medicare and Medicaid benefits.


Because Medicaid is generally the payer of last resort, Medicare-covered services, also covered by Medicaid, are first paid by Medicare. Medicaid may cover the cost of care that Medicare may not cover or may partially cover care, such as nursing home care, personal care, home- and community-based services, and so on.


Next, we will focus on the dual-eligible individuals who participate in the QMB program. Following are the questions that I received about the QMB program this past month.


Q: What exactly is the QMB program?


A: The QMB program is a Medicaid program for Medicare beneficiaries that exempts beneficiaries from liability for Medicare cost-sharing liability. State Medicaid programs may pay providers for Medicare deductibles, coinsurance, and copayments. However, as permitted by federal law, states can limit provider reimbursement for Medicare cost sharing under certain circumstances. (For further explanation, see next question.)


Those who are QMB beneficiaries also qualify for the full low-income subsidy for the Medicare Part D prescription drug benefit, including monthly premiums up to a given benchmark, no annual deductible, and nominal copayments per covered prescription.


Note: Wound care professionals are very likely to see dual-eligible QMB beneficiaries because approximately 7 million individuals currently participate in the program.


Q: Can providers "balance bill" QMP beneficiaries?


A: No. Federal law prohibits Medicare providers from balance billing QMB beneficiaries for all Medicare deductibles, coinsurance, or copayments. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. All original Medicare and Medicare Advantage providers-not only those that accept Medicaid-must refrain from charging QMB individuals for cost sharing.


Note: A state is not obligated to pay providers the full amount of Medicare cost sharing if the total payment (including both the Medicare portion and the state's portion) would exceed the state's Medicaid rate for that service. Instead, states may limit their reimbursement to the lesser of 2 amounts: the full amount of Medicare cost sharing, or the difference between the Medicaid rate and the amount already paid by Medicare. Most of the states limit Medicare cost-sharing payment levels for QMB beneficiaries at their Medicaid rates.


One more piece of information wound care professionals should know is that all Medicare providers must "accept assignment" for Part B services furnished to dual-eligible beneficiaries. Assignment means that the Medicare allowed amount constitutes payment in full for all Part B-covered services provided to beneficiaries.


Q: What will happen to providers who "balance bill" QMB beneficiaries for the Medicare deductible, coinsurance, and copayments?


A: Medicare providers are subject to sanctions if they bill QMB beneficiaries for amounts greater than the sum total of all Medicare and Medicaid payments (even when Medicaid pays nothing).


Q: How can wound care professionals identify QMB beneficiaries?


A: The following are several proactive steps to help wound care professionals identify their QMB beneficiaries and to help them communicate with state Medicaid agencies (and Medicare Advantage Plans, if applicable).


* Determine effective means to identify QMB beneficiaries among your patients. Find out what cards are issued to QMB beneficiaries so you can, in turn, ask all of your patients if they have that QMB card. Learn if you can query state systems to verify QMB enrollment among your patients. If you are a Medicare Advantage provider, contact the plan to determine how to identify the plan's QMB enrollees.


* Discern what billing processes apply to seek reimbursement for Medicare cost sharing from the state(s) in which you practice/operate. Different processes may apply to original Medicare and Medicare Advantage services provided to QMB beneficiaries. For original Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordinator & Recovery Center that automatically receive Medicare adjudicated claims.



If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare Remittance Advice.


Understand the processes you need to follow to request reimbursement for Medicare cost-sharing amounts if they are owed by your state. To bill the state, you may need to complete a State Provider Registration Process application and be entered into the state payment system.


Make sure that your billing software and administrative staff exempt QMB beneficiaries from Medicare cost-sharing billing and related collection efforts. In other words, make sure your billing software identifies QMB beneficiaries and does not generate bills to them for Medicare cost sharing.


Q: Do Medicare providers commonly balance bill QMB beneficiaries?


A: Unfortunately, despite federal law, erroneous balance billing of QMB beneficiaries persists.


Q: Why do QMB beneficiaries pay their Medicare deductibles, coinsurance, and copayments when they are exempt?


A: Many QMB beneficiaries are unaware of the billing restrictions. Some QMB beneficiaries are aware, but they are concerned about undermining relationships with their health care providers. Other beneficiaries experience undue distress when unpaid bills are referred to collection agencies.


Q: Can QMB beneficiaries "waive" their QMB status?


A: No. Federal statute clearly states that QMB beneficiaries cannot choose to "waive" the QMB status and pay Medicare cost sharing.


Q: If a QMB beneficiary receives care by a Medicare provider in a different state, can that provider balance bill the patient?


A: No. Qualified Medicare beneficiaries retain their protection from balance billing when they cross state lines to receive care. Providers cannot charge QMB beneficiaries, even if the patient's QMB benefit is provided by a different state than the state in which care is rendered.