Coding & Reimbursement

When Medicaid is part of the billing picture

The QMB Medicaid benefit has significant ramifications for your collections. Remain confused at your own peril.

Q. What is a Qualified Medicare Beneficiary (QMB)?

A. QMB is a Medicaid benefit established as part of the Medicare Catastrophic Coverage Act of 1988; it covers Medicare deductibles, coinsurance and copayments. Although nearly all of the provisions of this Act were repealed only a year later, QMB was retained.1 Federal guidelines have set an eligibility floor based on the federal poverty level and the value of a beneficiary’s resources. States can choose to make these limits more generous and include more beneficiaries in their programs, just as they can expand welfare benefits.2

In some states, the QMB program also pays the beneficiary’s Medicare premium, especially where Medicaid operates as managed-care plans.

Q. Why is this important?

A. You may not charge or collect any amount from these patients.2 Under federal law, patients enrolled in the QMB program are exempt from liability for Medicare deductibles, coinsurance or copayments (collectively, “cost-sharing”). Critically, balance-billing these patients would violate your Medicare provider agreement and could subject you to sanctions.

Q. Does QMB apply to Medicare Advantage (MA) Plans as well?

A. Yes. QMB applies to all Part B, Part C and DMEPOS claims, including MA.2 This means that you may not collect a MA Plan copayment from QMB patients.

Q. What if we are not Medicaid providers?

A. Even if you are not enrolled as a Medicaid provider, you are still subject to the QMB limitations. Since Medicaid will not pay you if you are not enrolled, you must write off Medicare cost-sharing balances; they cannot be billed to QMB patients.

Q. But what if Medicaid does not pay even if we are enrolled providers?

A. States may limit their liability to providers, usually by setting their fee schedules at or below the Medicare payment amount. Even if Medicaid does not pay, you are still prohibited from charging QMB individuals for Medicare cost-sharing and must write off the balance.

Q. If we do not participate with Medicare, are we still subject to QMB?

A. Not participating with Medicare usually means you can choose, on a case-by-case basis, whether to accept Medicare assignment. However, the QMB program applies to all Medicare providers, both participating and nonparticipating. This means you are obliged to accept assignment on all services to these patients, even if you would not do so otherwise.

Q. How do we identify these QMB patients?

A. Clearly, it’s best to know QMB status in advance; some states make this easier than others. When it’s not possible (such as when the state has not updated the status list and you are checking for today’s exam), there are three Remittance Advice (RA) codes to look for when claims are paid.

  • N781 – No deductible may be collected
  • N782 – No co-insurance may be collected
  • N783 – No copayment may be collected

Each RA code also instructs you to “Review your records for any wrongfully collected amounts above.” Immediately refund any amount collected in error. CMS issued instructions to establish a new section to Chapter 1 (Section 200) of the Medicare Claims Processing Manual for QMB.

Also, as of November 2017, CMS notes that providers can use a new option — HIPAA Eligibility Transaction System (HETS) — to identify Medicare QMB eligibility. You must be enrolled in HETS.3 (For information on how to enroll, go to: )

Q. Suppose the patient wants to pay us outside of any insurance; can we do that?

A. Maybe, but tread carefully. Don’t forget that many Medicaid programs cover services that Medicare does not, and MA plans also offer additional coverage (such as routine eye care). QMB patients cannot choose to waive their QMB status and pay Medicare cost-sharing,4 so you could be accused of balance-billing — a serious offense. Only if you are absolutely sure that a service is not covered could you collect from the patient; we recommend getting something in writing to support you. OM


  1. H.R. 3607 (101st): Medicare Catastrophic Coverage Repeal Act of 1989. . Accessed Nov. 29, 2017.
  2. CMS Transmittal 3715. Qualified Medicare Beneficiary Indicator in the Medicare Fee-for-Service Claims Processing System. . Accessed Nov. 29, 2017.
  3. CMS. HIPAA Eligibility Transaction System (HETS). . Accessed Nov. 29, 2017.
  4. MLN Matters SE1128. Revised Nov 13, 2017. . Accessed Nov. 29, 2017.