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A friendly reminder: You can’t balance bill Medicare beneficiaries


Some dual-eligible Medicare beneficiaries have additional benefits — providers can’t charge these members for cost sharing.

 

State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. But federal law allows states to limit provider reimbursement for Medicare cost sharing under certain conditions. Dual-eligible individuals may qualify for Medicaid programs that pay Medicare Part A and B premiums, deductibles, coinsurance and copays to the extent that the state Medicaid plan provides. These programs include the following:

  • Qualified Medicare Beneficiary (QMB)
  • Specified Low-Income Medicare Beneficiary (SLMB)
  • Qualified Disabled and Working Individuals (QDWI)
  • Qualifying Individual (QI)

 

Medicare providers must accept the Medicare and Medicaid payment (if any) in full for services given to a beneficiary within one of these Medicare Savings Programs. Failure to follow these billing rules is a violation of applicable law and a breach of your provider agreement. Plus, providers who fail to comply may be subject to sanctions.

 

Tips

  •  All Original Medicare and Medicare Advantage providers — not just those that accept Medicaid — must follow the balance-billing rules.
  • Providers can’t balance bill these members when they cross state lines for care, no matter which state provides the benefit.

 

More information