Medicaid’s Qualified Medicare Beneficiary (QMB) program assists low-income beneficiaries with Medicare premiums, deductibles, coinsurance, and Medicare Advantage Plan co-pays. Often referred to as “dual eligible beneficiaries,” these individuals are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums, or cost sharing through one of four “Medicare Savings Programs” (MSP):
Physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.
Currently, neither the Medicare eligibility systems (HIPAA Eligibility Transaction System) nor the claims processing systems (the FFS Shared Systems) notify providers and suppliers about their patient’s QMB status and lack of Medicare cost-sharing liability. Likewise, Medicare Summary Notices (MSNs) do not inform those enrolled in the QMB program that they do not owe Medicare cost-sharing for covered medical items and services. However, providers and suppliers can expect changes to this process with the implementation of CMS Change Request (CR) 9911.
Change Request (CR) 9911 includes modifications to the FFS claims processing systems and the “Medicare Claims Processing Manual” to generate notifications to Medicare providers and beneficiaries regarding beneficiary QMB status and lack of liability for cost-sharing.
With the implementation of CR 9911, Medicare’s Common Working File (CWF) will provide the claims processing systems with the following QMB indicators (RARC & CARC) if the dates of service coincide with a QMB coverage period for claims processed on or after October 2, 2017:
Beneficiaries will be notified through their Medicare Summary Notice (MSN).
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