CMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed

The Centers for Medicare and Medicaid Services (CMS) is changing reimbursement summaries sent to beneficiaries and providers to plainly state that low income beneficiaries with Qualified Medicare Beneficiary (QMB) status are exempt from paying Medicare cost sharing.

Beginning October 3, 2017, the Medicare Summary Notice (MSN) clearly identifies when the beneficiary was enrolled in the QMB program and will show a $0 balance owed for beneficiaries.

CMS is also adding information and messages to CMS' HIPPA Eligibility Transaction System (HETS) on November 4, 2017 regarding QMB status. The HETS allows providers to check Medicare beneficiary eligibility data in real-time. Including the QMB information in this system will ensure that providers are aware of QMB status in real-time, so they do not illegally bill individuals for cost-sharing.

Beneficiaries enrolled in the QMB program are excused, by law, from paying Medicare cost-sharing for all Medicare Part A and Part B claims.  This includes deductibles, coinsurance and copays. Providers are prohibited from charging them. Beneficiaries enrolled in the QMB program are, by definition, low income. In order to be eligible for the program the individual's monthly income must be at or below 100% of the annual Federal Poverty Level and have limited resources.

Despite this prohibition, a 2015 CMS study found that providers illegally balance-billed participants for Medicare cost-sharing on a regular basis. Due to a lack of information, confusion regarding the system, or concern over outstanding bills, most QMB enrollees participating in the study paid these bills. Additionally, participants reported that unpaid bills were submitted to collection agencies. For beneficiaries with such low incomes, any cost sharing amount can be cost prohibitive and lead to difficult choices regarding paying for other necessities like food and medications, or lead them to forgo necessary medical appointments or care.

The Center for Medicare Advocacy applauds these CMS changes, aimed at ensuring that low-income beneficiaries are not illegally billed by providers. These changes should eliminate such billing from providers who are simply unaware of the program itself, or unaware of a patient’s enrollment in the program. The Center thanks CMS for addressing balance billing of low-income Medicare beneficiaries.

For more information see: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
More information on QMB status see:

• http://www.medicareadvocacy.org/medicare-cost-sharing-for-qualified-medicare-beneficiaries/
• https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB.html