QMB-only Medicare recipients
QMB-only Medicare recipients are identified as QMB ONLY by using the Provider Electronic Solutions software, AVRS (Automated Voice Response System) or the Provider Assistance Center.
These recipients are eligible only for crossover services and ARE NOT eligible for Medicaid only services. That is, if Medicare covers the service, Medicaid will consider for payment the deductible and/or co-insurance. Premiums and copayment will be considered for payment if the individual is enrolled in a Medicare Advantage Plan.
Category 2 QMB Medicare/Medicaid recipients
QMB Medicare/Medicaid recipients are identified as having Medicaid and QMB (QMB+) when eligibility is verified through the Provider Electronic Solutions software, AVRS, or the Provider Assistance Center.
These recipients are eligible for the same benefits as QMBonly recipients (category 1) and Medicaid/Medicare recipients (category 3).
Category 3 Medicare/Medicaid recipients
Medicare/Medicaid recipients who do not qualify as QMB are identified as having part ‘A’, ‘B’, or ‘A & B’ when their eligibility is verified through the Provider Electronic Solutions software, AVRS, or the Provider Assistance Center.
Medicare-related claims for Medicare/Medicaid recipients will be paid only if the services are covered under the Alabama Medicaid Program.
LIST AND DEFINITION OF DUAL ELIGIBLES
Dual Eligibles – The following describes the various categories of individuals who, collectively, are known as dual eligibles. Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services. Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.
1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) – These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for
Medicare services provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
2. QMBs with full Medicaid (QMB Plus) – These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance, and provides full Medicaid benefits. FFP equals FMAP.
3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) – These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. FFP equals FMAP.
4. SLMBs with full Medicaid (SLMB Plus) – These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits. FFP equals FMAP.
5. Qualified Disabled and Working Individuals (QDWIs) – These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP.
6. Qualifying Individuals (1) (QI-1s) – This group is effective 1/1/98 – 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 120% FPL, but less than 135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. FFP equals FMAP at 100%.
7. Qualifying Individuals (2) (QI-2s) – This group is effective 1/1/98 – 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 135% FPL, but less than 175% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays only a portion of their part B premiums ($2.23 in 1999). FFP equals FMAP at 100%.
8. Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, QI-1, or QI-2) – These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI-1, or QI-2. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits listed above. Medicaid provides full Medicaid benefits and pays for Medicaid services provided by Medicaid providers, but Medicaid will only pay for services also covered by Medicare if the Medicaid payment rate is higher than the amount paid by Medicare, and, within this limit, will only pay to the extent necessary to pay the beneficiary’s Medicare costsharing liability. Payment by Medicaid of Medicare Part B premiums is a State option; however, States may not receive FFP for Medicaid services also covered by Medicare Part B for certain individuals who could have been covered under Medicare Part B had they been enrolled. FFP equals FMAP.
Important Clarifications Concerning QMB Balance Billing Law
Be aware of the following policy clarifications to ensure compliance with QMB balance billing requirements. First, know that all original Medicare and MA providers– not only those that accept Medicaid– must abide by the balance billing prohibitions.
In addition, QMB individuals retain their protection from balance billing when they cross state lines to receive care. Providers cannot charge QMB individuals even if the patient’s QMB benefit is provided by a different State than the State in which care is rendered.
Finally, note that QMBs cannot choose to “waive” their QMB status and pay Medicare cost-sharing. The federal statute referenced above supersedes Section 3490.14 of the “State Medicaid Manual,” which is no longer in effect.
Ways to Improve Processes Related to QMBs Proactive steps to identify QMB individuals you serve and to communicate with State Medicaid Agencies (and Medicare Advantage plans if applicable), can promote compliance with QMB balance billing prohibitions.
1. Determine effective means to identify QMB individuals among your patients. Find out what cards are issued to QMB individuals so you can in turn ask all your patients if they have them. 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.
2. Discern what billing processes apply to seek reimbursement for Medicare cost-sharing from the States in which you operate. Different processes may apply to original Medicare and MA services provided to QMB beneficiaries. For original Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordination & Recovery Center (BCRC) to 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. You may need to complete a State Provider Registration Process and be entered into the State payment system to
bill the State.
3. Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts.
QMB Eligibility and Benefits Dual Eligibility Eligibility Criteria Benefits Qualified Medicare Beneficiary (QMB only)
• Resources cannot exceed $7,280 for a single individual or $10,930 in 2015 for an individual living with a spouse and no other dependents.
• Income cannot exceed 100% of the Federal Poverty Level (FPL) +$20 ($1,001/month – Individual $1,348/month – Couple in 2015).
Note: These guidelines are a federal floor. Under Section 1902 (r)(2) of the Social Security Act, states can effectively raise these limits above these baseline federal standards.
Medicaid Pays Medicare Part A and B premiums, deductibles, co-insurance and co-pays to the extent required by the State Medicaid Plan.
• Exempts beneficiaries from Medicare cost-sharing charges
• The State may choose to pay the Medicare Advantage (Part C) premium.
QMB Plus
• Meets all of the standards for QMB eligibility as described above, but also meets the financial criteria for full Medicaid coverage
Provides all benefits available to QMBs, as well as all benefits available under the State Plan to a fully eligible Medicaid recipient
Verifying the QMB status of out-of-state beneficiaries
Q. How can I verify the Qualified Medicare Beneficiary (QMB) status of an out-of-state beneficiary?
A. Providers and suppliers can verify beneficiaries’ QMB status through state online Medicaid eligibility systems in the state in which the person is a resident or by asking beneficiaries for other proof, such as their Medicaid identification card or documentation of their QMB status.
Why can’t I locate the deductible information when checking a patient’s eligibility?
If the beneficiary is enrolled as a Qualified Medicare Beneficiary (QMB), deductible information may not be available at the time of the query.
As of November 4, 2017, HETS (HIPAA Eligibility Transaction System) indicates periods during which the beneficiary is enrolled as a QMB, and will indicate the beneficiary owes $0 for Medicare Part A and B deductibles, coinsurance or copayments. Note: This information will be displayed under the QMB tab within SPOT.
QMB beneficiaries have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. For these beneficiaries, Medicaid is responsible for covering Medicare cost-sharing, though the beneficiary may also have other secondary payers (e.g., VA, tribes, Medigap).
MEDICARE/MEDICAID DUALLY ELIGIBLE BENEFICIARIES: Medicaid will continue to pay the full annual Medicare Part B deductible as well as the full 20% Medicare Part B coinsurance amounts for all APG Medicare/Medicaid “crossover” claims – crossover claims will bypass the APG grouper. However, clinics with rate codes 1407, 1435, and 1428 serving persons with an RE (recipient Managed Care exempt restriction) code of 95 on file in the eMedNY system and FQHCs will continue to be paid the higher of:
** The full Medicare Part B coinsurance amount, or
** The difference between the Medicare paid amount and the calculated APG payment.
