Practice Considerations Related to QMB (Qualified Medicare Beneficiary) Status

QMB (Qualified Medicare Beneficiary) is a state Medicaid benefit established as part of the Medicare Catastrophic Coverage Act in 1988 that covers Medicare deductibles, coinsurance and copayments. Although nearly all of the provisions of this Act were repealed only a year later, QMB was retained. Federal guidelines set an eligibility floor based on the federal poverty level and the value of a beneficiary’s resources. States can choose to make these limits more generous and include more beneficiaries in their programs, just as they can expand welfare benefits.

In some states, the QMB program also pays the beneficiary’s Medicare premium, especially where there are dual-eligible managed care plans.

  1. What is a Qualified Medicare Beneficiary (QMB)?
  2. Why should practices take care to properly identify these beneficiaries?
  3. Does QMB apply to Medicare Advantage (MA) Plans as well?
  4. Are we still subject to QMB if we are not Medicaid providers?
  5. What if Medicaid does not pay even if we are enrolled providers?
  6. If we are not participating with Medicare, are we still subject to QMB?
  7. If the patient we are seeing is from out-of-state, does QMB still apply to us?
  8. Suppose the patient wants to pay us outside of any insurance; can we do that?
  9. How do we identify these QMB patients?
  10. Does Medicare offer any other advice?

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