Back to Insights and Updates for ProvidersDecember 2023

Reminder: QMB Members Exempt from Part A/B Cost-Sharing

Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Senior Care Options  |  Tufts Medicare Preferred

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. For Harvard Pilgrim members, when we are aware that a claim is for a member who is a qualified Medicare beneficiary, a message appears on the member’s Explanation of Benefits statement, as well as the provider’s Explanation of Payment, to identify this status.

The Explanations of Payment that Tufts Health Plan sends 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, as well as the Billing Members policy in Harvard Pilgrim’s Medicare Advantage Provider Manual.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ryan Francis, Stephen Wong,

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