Qualified Medicare Beneficiary (QMB) Program

The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries. In 2017, 7.7 million people (more than one out of eight people with Medicare) were in the QMB program.

Billing Protections for QMBs

Federal law forbids Medicare providers and suppliers, including pharmacies, from billing people in the QMB program for Medicare cost sharing. Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or Part B deductibles, coinsurance, or copays for any Medicare-covered items and services.

Despite the federal law, our July 2015 study ("Access to Care Issues Among QMBs") (PDF) found that those in the QMB program were still being wrongly billed and that confusion about billing rules continued. We have taken several steps since to help Medicare providers and beneficiaries better understand the QMB protections, including through many of the resources below. 

Information for Medicare Providers & Suppliers

• Dual Eligible Beneficiaries under the Medicare and Medicaid Programs (PDF)
• Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program (PDF)
• Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of QMBs for Medicare Cost-Sharing (PDF)
• QMB Program Billing Requirements Call (06/06/2018)
• QMB Program FAQ on Billing Requirements (PDF)
• CMS Systems Changes  - Timeline for QMB Remittance Advice (RAs) & the MSNs
  • July, 2018: CMS reintroduced QMB information in the RA without disrupting claims processed by secondary payers (MM10433 (PDF))
  • October, 2019: CMS will further modify the Medicare Summary Notice (MSN) for QMBs to reflect zero cost-sharing liability only for paid claims, not for claims that are denied (MM11230 (PDF))

Information for Medicare Advantage Plans

• Qualified Medicare Beneficiary Program Information in Remittance Advice and Explanation of Benefits (4/3/2018) (PDF) (Health Plan Management System (HPMS) Memo)
• CY 2019 Part C & Part D Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, Medicare-Medicaid Plans, and Cost Plans (PDF) (10/02/2018) (HPMS Memo)
  • CY 2019 Part C & Part D Readiness Checklist Appendix A for Medicare Advantage Organizations, Prescription Drug Plans, Medicare-Medicaid Plans, and Cost Plans (PDF) (10/02/2018) (HPMS Memo)
• Qualified Medicare Beneficiary Program Enrollee Status Resources (6/21/2017) (PDF) (HPMS Memo)
• Preventing Improper Billing of Medicare-Medicaid Enrollees in Managed Care: Strategies for States and Dual Eligible Special Needs Plans

Information for Medicare Beneficiaries & their Advocates

• 3 Tips for People in the QMB Program (English & Spanish)
• Seniors & Medicare and Medicaid Enrollees
• Medicare Savings Programs
• Medicare-Medicaid Enrollee Categories (PDF)

Information for States

• Medicaid Third Party Liability & Coordination of Benefits
• Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program (PDF)
• Payment of Medicare Cost Sharing for QMBs
• Billing for Services Provided to QMBs
• Medicare Competitive Bidding Program for Durable Medical Equipment and Coordination of Benefits for Beneficiaries Eligible for Medicare and Medicaid (Dual Eligibles)
• Preventing Improper Billing of Medicare-Medicaid Enrollees in Managed Care: Strategies for States and Dual Eligible Special Needs Plans

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