Warning: No Balance Billing for Dual Eligibles

The Centers for Medicare & Medicaid Services (CMS) reissued guidance recently to remind physicians of the prohibition on balance billing for patients who are covered by both Medicare and Medicaid. 

"Despite federal law, erroneous balance billing of QMB [Qualified Medicare Beneficiary] individuals persists," the agency advised. "Many beneficiaries are unaware of the billing restrictions (or concerned about undermining provider relationships) and simply pay the cost-sharing amounts."

Medicare and Medicaid payments that physicians receive for furnishing services to dual-eligible patients are considered payment in full, even in states like Texas where Medicaid does not cover the full Medicare cost-sharing amounts. 

The CMS guidance further states: 

  • All original Medicare and Medicare Advantage physicians and providers — not just those who accept Medicaid — must abide by the balance billing prohibition.
  • Dual-eligible patients retain their protection from balance billing when they cross state lines to receive care. 
  • Dual-eligible patients cannot choose to "waive" their QMB status and pay Medicare cost-sharing.
  • Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions   

In January 2012, Texas Medicaid stopped paying dual-eligible patients' Medicare deductible. The program also stopped paying the patients' coinsurance (due if Medicare's payment to the physician exceeded what Medicaid pays for the same service, which is usually the case).

One year later, under the direction of the Texas Legislative Budget Board, the Texas Health and Human Services Commission restored coverage of the Medicare deductible for dual-eligible patients. Texas Medicaid still will not cover the coinsurance. Restoration of this payment — along with increasing physician Medicaid payments generally — will be a high priority for TMA during the 2017 legislative session.

Action, July 15, 2016

Last Updated On

April 27, 2018

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