QMB stands for “Qualified Medicare Beneficiary” and is a cost assistance program designed to help individuals who are eligible for both Medicare and Medicaid, a circumstance that is known as “dual eligibility.”
The QMB program helps pay for the full cost of Medicare Part A and Part B premiums along with complete coverage of deductibles, copayments and coinsurance. QMB offers the most comprehensive coverage of the programs available to dual-eligible beneficiaries.
QMB enrollees face no out-of-pocket costs for care that is covered by Medicare Part A or Part B that is administered at a Medicare-approved facility by an approved provider. States do have the right to impose their own laws related to QMB that may override federal regulations, but any costs to the beneficiary would be minimal.
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In addition to covering Medicare premiums for eligible QMB recipients, one of the benefits of the QMB program is having protection from improper billing. Improper billing refers to when health care providers inappropriately bill a beneficiary for deductibles, copayments or coinsurance.
Federal law prohibits providers from billing beneficiaries enrolled in the QMB program for any such costs. This law even pertains to non-participating providers, who are allowed to charge other Medicare beneficiaries more for care.
QMB beneficiaries who are enrolled in Medicare Advantage plans are also protected from any cost-sharing requirements when receiving covered care from in-network providers.
The QMB improper billing protection even extends to health care providers who do not accept Medicaid. That means QMB members may receive care from a provider who does not accept Medicaid and still receive protection from deductibles, copayments and coinsurance.
Providers who do not adhere to QMB improper payment protection guidelines may be subject to penalties.
You must be eligible for both Medicare and Medicaid to be eligible for QMB benefits. While Medicare’s eligibility requirements are federally mandated, each state may set its own qualifying restrictions for Medicaid.
You must also meet the QMB income and resource limits in 2021:
To apply for the QMB program, contact your state Medicaid program. Please not that if your income or financial resources are close to the totals listed above, you should still apply, as you may potentially be eligible.
QMB is not the only program available to dual-eligible beneficiaries. Others include:
Dual-eligible beneficiaries may also enroll in a Dual-eligible Special Needs Plan (D-SNP). This is a particular type of Medicare Advantage plan with a benefits package that is tailored to the needs of those with the limited income and resources common among Medicaid recipients.
Special Needs Plans are sold by private insurance companies, so contact a licensed insurance agent for additional information. You can also compare plans online to see if there are Medicare SNPs available where you live.
Speak with a licensed insurance agent
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.
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