Dear Marci,
I applied for the Medicare Savings Program and just received a letter stating that I am eligible for the Qualified Medicare Beneficiary (QMB) level of the Medicare Savings Program. What benefits and protections are included with QMB?
-Jonah (Tampa, FL)
Dear Jonah,
Qualified Medicare Beneficiary (QMB) is one of three main Medicare Savings Programs (MSPs).The MSPs help pay your Medicare costs if you have limited income and savings. If you qualify for QMB, it will pay your Medicare Part A and B premiums and cost-sharing. Cost-sharing can include deductibles, coinsurance, and copayments. Federal law prohibits Medicare providers from billing people enrolled in the QMB program for any Medicare cost-sharing. This means that if you have QMB, Medicare providers should not bill you for any Medicare-covered services you receive.
More specifically, if you have QMB and are enrolled in Original Medicare, you should not be billed when receiving a Medicare-covered service from either:
- A participating provider: A provider who accepts Medicare and always takes assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment.
- A non-participating provider: A provider who accepts Medicare but has not agreed to take assignment in all cases.
If you have QMB and are enrolled in a Medicare Advantage Plan, you should not be billed when receiving a plan-covered service from:
- In-network providers, as long as you meet your plan’s coverage rules, such as getting prior authorization to see certain specialists
To protect yourself from improper billing, be aware that:
- Original Medicare and Medicare Advantage providers who do not accept Medicaid must still comply with improper billing protections and cannot bill you
- You keep your improper billing protections even when receiving care from Medicare providers in other states (Note: you can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider)
- You cannot choose to waive these protections and pay Medicare cost-sharing, and a provider cannot ask you to do this
Note: Some states may impose Medicaid copays for certain Medicare-covered services. Medicare and Medicaid should pay the majority of the cost, leaving you a nominal copay. Contact your local Medicaid office to learn more about Medicaid copays in your state.
Remember that if you have QMB, the Medicare providers you see must accept Medicare payment and any QMB payment as the full payment for any Medicare-covered services you received. Providers who violate improper billing protections may be subject to penalties. If you are having issues with a provider who continually attempts to bill you, or if you have unpaid cost-sharing bills that have been sent to collection agencies, call 1-800-MEDICARE or contact your Medicare Advantage Plan.
Marci