MA Plan Dual eligible QMB
Qualified Medicare Beneficiaries (QMBs) fall into two categories:
•QMB only – those beneficiaries who just receive assistance paying for their Medicare premiums and cost-sharing.
• QMB plus – those beneficiaries who are also eligible for full Medicaid benefits.
Special rules apply to QMBs:
•When a QMB enrolls in an MA plan, the beneficiary does not have to pay more cost-sharing than any minimal copayment that would apply under Medicaid. •All providers (whether or not they are Medicaid participating, or in-network) are prohibited by law from balance billing QMBs for any Medicare cost-sharing amounts. Providers who balance bill are subject to sanctions
MA Plan Dual eligible QMB case Study Case Study
Mr. Walsh is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Mr. Walsh goes to his primary care doctor to receive a Medicare covered service. The normal copayment is $25.00. The doctor may only collect from Mr. Walsh any minimal cost sharing allowable under the state Medicaid program which in Mr. Walsh’s case is $2.00 for his physician visit. His doctor may bill the state for the cost sharing, but the hold harmless obligation applies regardless of whether or how much of the cost sharing the state pays.
