The Qualified Medicare Beneficiary (QMB) program put in place by the Centers for Medicare and Medicaid Services (CMS) assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copayments. As a reminder, under the QMB program enrollees are exempt from cost-sharing liability, so all providers are prohibited from charging QMB members for Medicare cost-sharing for covered Parts A and B services.
Identifying members with QMB status
CMS’s HIPAA Eligibility Transaction System (HETS) provides Medicare eligibility data to providers and their authorized billing agents (including clearinghouses and third-party vendors) to help verify a patient’s QMB status and exemption from cost-sharing charges. Contact your third-party eligibility verification vendor to ask how their products reflect the new QMB information from HETS.
In addition, Point32Health provides the necessary information to our members and providers regarding QMB eligibility.
The Explanations of Payment we send to providers include an alert that the notice may contain claims covered by the QMB program and remind providers to review their records for any wrongfully collected cost-sharing, which may be billed to a subsequent payer.
More information
For more detailed information about CMS’s QMB program, please refer to this document from the Medicare Learning Network.