Jan. 23, 2025
If you participate in Blue Cross Medicare AdvantageSM plans, you may not bill our members enrolled in the Qualified Medicare Beneficiary program, a federal Medicare savings program.
QMB patients are dual eligible beneficiaries, which means they are eligible for both Medicare and Medicaid. QMB covers the Medicare Advantage premiums, deductibles, coinsurance and copayments of QMB beneficiaries. QMB beneficiaries are not responsible for Medicare Advantage cost-sharing or out-of-pocket costs.
Per the Centers for Medicare & Medicaid Services, you may not refuse service to QMB patients because they are protected from paying cost sharing. For services you provide to QMB patients, you must accept Medicare Advantage payments and any Medicaid payments as payment in full. CMS advises providers to take action to remedy any QMB billing or collections.
For more details about QMB: Refer to the CMS website and fact sheet.
To avoid billing QMB patients: Ensure that you and your staff are aware of the federal billing law and policies governing QMB. It is against federal law for any Medicare provider to bill QMB patients, whether or not the provider accepts Medicaid. Per your Medicare Provider Agreement, you may be sanctioned if you inappropriately bill QMB patients for Medicare Advantage cost-sharing. Please take these precautions:
- To check our members’ eligibility, benefits and QMB beneficiary status, sign in to Availity® Essentials.
- Follow instructions on the member ID card to submit claims.
- Be sure your billing software and staff remove QMB patients from Medicare Advantage cost-sharing billing and related collections efforts.
Questions? Call customer service at 877-774-8592.
The information provided here is only intended to be a summary of the law that has been enacted and is not intended to be an exhaustive description of the law or a legal opinion of such law. If you have any questions regarding the law mentioned here, you should consult with your legal advisor.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Blue Cross and Blue Shield of Oklahoma. BCBSOK makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.