Balance Billing

It is prohibited by federal law to balance bill members enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance and copay, subject to state payment limits. Medicare providers may not balance bill QMB members for Medicare cost sharing, regardless of whether the state reimburses providers for the full Medicare cost sharing amounts.

This includes members enrolled in the Horizon NJ TotalCare (HMO D-SNP) program, our dual eligible special needs plan (D-SNP). Providers cannot balance bill D-SNP members for any services.

Further, all original Medicare and Medicare Advantage providers, not only those that accept Medicaid, must refrain from charging Horizon NJ TotalCare (HMO D-SNP) members for Medicare cost sharing. Providers who inappropriately balance bill these members are subject to sanctions.

For more information on the Federal law regarding balance billing QMB beneficiaries, see Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.

Thank you for your continued commitment to the best health outcomes for our members. If you have any questions, please call Provider Services at 1-800-682-9091.