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ALL Medicare providers: federal law prohibits balance billing of dual-eligible patients

01/29/2018

This is a reminder to our Medicare Advantage providers about the proper treatment and billing of patients who are eligible for both Medicare and Medicaid and designated as Qualified Medicare Beneficiaries (QMBs):

  • Our contracts require all our Medicare providers to see all our Medicare Advantage members, including those who are eligible for both Medicare and Medicaid (often called "dual eligible").
  • The Centers for Medicare & Medicaid Services (CMS) forbids Medicare providers from discriminating against patients based on "source of payment," which means providers cannot refuse to serve members because they receive assistance with Medicare cost-sharing from a State Medicaid program.
  • Federal law prohibits balance billing of these QMBs or dual eligible patients for any Medicare cost-share, including deductibles, coinsurance and copayments.

This applies to all Medicare providers, regardless of whether they accept Medicaid.

The QMB program is a Medicaid program that exempts Medicare beneficiaries from having to pay their Medicare cost-shares. If providers want to get paid a patient's cost-share, the bill of service may be submitted to Medicaid for reimbursement.

For more information, check out this Medicare Learning Network resource