How Does QMB Work and What’s the Impact on DME Providers?

The Qualified Medicare Beneficiary (QMB) program is a Medicare Savings Program (MSP) that assists low-income Medicare beneficiaries. This program makes it possible for these individuals to receive the medical services and devices they need that they might not usually receive due to their lack of financial resources.

While this program is making strides toward helping Americans, how does it impact HME and DME providers? This article will take a deeper look into the QMB program and its impact on your business. 

How Does QMB Work?

The QMB program assists “dual-eligible beneficiaries.” Which are low-income individuals enrolled in both Medicare and Medicaid. The program helps them with their:

  • Medicare services, deductibles, and coinsurance
  • Medicare Advantage Plan co-pays
  • Medicare Part A and Part B premiums
  • Paying for prescription drug costs (Medicare Part D)

It’s also important to note that QMB program enrollees have no legal obligation to pay their Medicare Part A/B deductibles, coinsurance, or copays.

Additionally, this initiative allows them to receive full Medicaid benefits. To qualify for the program, beneficiaries must be:

  • Medicare eligible (Medicare Part A and/or Part B)
  • A District resident
  • A US citizen or have eligible immigration status
  • Have income up to 300% of the Federal Poverty Level 
    • As of 2022, the monthly income limit for eligibility is $1,153 for individuals and $1,546 for married couples. Review the Medicare Savings Program’s site for the most recent income eligibility. 

Other Details About QMB 

Along with being enrolled in the QMB program, these same individuals might also qualify for additional MSPs, including:

  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled Working Individual (QDWI) Program

How Does QMB Impact DME Providers?

While this initiative benefits many individuals, as mentioned above, they aren’t obligated to pay for any Medicare-covered items and services. As of 2017, 7.7 million people participate in the QMB program (source). So, you might wonder how it impacts HME and DME providers. 

Federal law prohibits all Medicare providers and suppliers from billing QMB program individuals for Medicare cost-sharing. Learn more about the prohibition of billing these beneficiaries

Additionally, federal law permits states to limit provider payment for Medicare cost-sharing services or devices (under certain circumstances). Providers can request reimbursement for any unpaid Medicare deductible and coinsurance amounts under the Centers for Medicare and Medicaid Services (CMS) Pub. 15-1, Chapter 3 of the “Provider Reimbursement Manual (PRM).”

To make the request, you’ll need to list your claim as “Medicare bad debt related to dually eligible beneficiaries.” Additionally, you may need to complete a State Provider Registration Process to enter your business into your state’s payment system. Also, note that you can contact your state’s agency administering the program for any questions or concerns. The Medicare Administrative Contractors are unable to help with your questions.

Additional Resources 

Within the last few years, there’s still confusion regarding billing QMB recipients. And there are several resources you can review for the specific information that CMS has provided. 

CMS’s Qualified Medicare Beneficiary (QMB) Program Website

FAQ on QMB Program Billing Requirements

Noridian Healthcare Solutions on QMB Program 

Contact Us to Learn How Medbill Can Help You 

At Medbill, our team of experienced billers can assist your business with submitting reimbursement claims for QMB beneficiaries. Contact us to learn what we can do to help you navigate these billing scenarios.