Do Not Bill QMB Program Members

Under Federal law, Qualified Medicare Beneficiaries (QMB) program members are not responsible for copayments and/or other cost sharing for covered services, supplies or items.

For details about the QMB program, please visit the CMS Qualified Medicare Beneficiary (QMB) Program webpage or CMS Medicare Learning Network’s Beneficiaries Dually Eligible for Medicare & Medicaid.

Please review the information below about your responsibilities in regard to treating and billing QMB program members.

In which plans can QMB program members be enrolled?

QMB program members may be enrolled in either a:

  • Braven HealthSM Medicare Advantage plan
  • Horizon NJ TotalCare (HMO D-SNP) plan

How to identify QMB program members

QMB program members receive a letter confirming their status, and you may ask your patients about this letter. However, rather than relying solely on QMB members to self-report we suggest also using one of the methods below to identify QMB program members:

  1. The preferred method for confirming QMB program member status is through the CMS HIPAA Eligibility Transaction System (HETS).
  2. Follow the instructions in the 270/271 HIPAA Companion Guide, accessible via the New Jersey Medicaid Management Information System (NJMMIS). Note that not all QMB members have full Medicaid, so you will not be able to identify the status of all QMB program members through NJMMIS.

    To access this guide, from the NJMMIS website:

    • Click "Forms & Documents"
    • Select "Provider" in the Choose a Type menu and "HIPAA" in the Choose a Topic menu
    • Click "270/271 HIPAA Companion Guide (Version 5010)"

Explanation of Payment (EOP) statements

Horizon NJ TotalCare (HMO D-SNP) EOP statements display the appropriate cost-sharing information for QMB program member claims.

Unfortunately, the patient cost-sharing information displayed on Braven Health EOPs may not be accurate for QMB program members enrolled in Braven Health plans. Please contact Provider Services if you have questions about the patient cost-sharing amounts displayed on Braven Health EOPs.

Receiving Reimbursement for QMB program member cost-sharing amounts

While you may not bill QMB program members for patient cost-sharing amounts, you may bill the appropriate State source for any QMB program member cost-sharing amounts.

Published on: December 12, 2022, 05:21 AM ET
Last updated on: December 8, 2022, 05:29 AM ET