How to Identify Dual-Eligible Patients

You must accept as payment in full the Medicare payment and Medicaid payment for services you provide to a patient enrolled in the Qualified Medicare Beneficiary (QMB) program.

This Medicaid program helps low-income patients with Medicare premiums and cost-sharing. You may not balance bill QMB, or dual-eligible, patients for Medicare deductibles, coinsurance, or copays. You may, however, bill Texas Medicaid for QMB patient deductible amounts. (See the Texas Medicaid Provider Procedures Manual, 6.12 Filing Medicare Primary Claims, for information about submitting claims for QMB patients.)

The Centers for Medicare & Medicaid Services has been working to rein in improper billing of QMB-enrolled patients, and recommends you establish processes to routinely identify the QMB status of your Medicare patients before billing for items and services. You can verify status in several ways:

  • Starting Nov. 4, you can use the HIPAA Eligibility Transaction System (HETS) to verify a patient’s QMB status and exemption from cost-sharing charges. HETS will indicate periods during which a beneficiary is enrolled in QMB and owes $0 for Medicare deductibles, coinsurance, and copayments
  • You can identify patients’ QMB status and billing prohibitions on the Medicare remittance advice, which will contain new relevant notifications and information about claims processed on or after Oct. 2. 
  • Medicare Advantage physicians should contact the MA plan to learn the best way to identify the QMB status of plan members.
  • Verify a patient’s QMB status through the state Medicaid eligibility system.
  • Ask patients for items such as their Medicaid identification card, which will say “QMB” or “MQMB,” or a copy of their Medicare Summary Notice that reflects, among other things, the patients’ QMB status for claims processed on or after Oct. 2, 2017.

Ensure your billing procedures and third-party vendors exempt individuals enrolled in the QMB program from Medicare charges and that you remedy billing problems should they occur. If you have erroneously billed patients enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.

For more information and helpful links, see CMS’ MLN Matters No. SE1128 Revised. See also TMA’s white paper (TMA log-in required) on payment for dual-eligible patients (TMA log-required), and the TMA Dual Eligibles webpage.

Published Oct. 30, 2017

Last Updated On

August 23, 2023

Originally Published On

October 30, 2017

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