Understanding Your QMB Dual Eligibles

The Centers for Medicare & Medicaid Services (CMS) Advance Notice and Call Letter included additional reminders to plans about managing Qualified Medicare Beneficiaries (QMBs). A QMB is a dual-eligible beneficiary who does not have full Medicaid. Instead, that individual has Medicare cost-sharing subsidies by the state Medicaid program for Part A and B covered deductibles and coinsurances. When a QMB member is part of a Medicare Advantage (MA) plan, it becomes the MA plan’s responsibility to ensure providers do not balance bill the member for the plan deductibles and cost sharing for Medicare-covered services provided by the MA plan.

Health plans have historically struggled to identify QMB status. CMS is encouraging plans to remind their providers they can verify this information in the HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (HETS) eligibility query system. Part of the contractual requirements between CMS and plans and between MA plans and their contracted providers is an agreement that providers will not balance bill members.

CMS suggested health plans utilize a variety of means to educate their providers to prevent inappropriate member billing:

  • Adding language to provider-focused websites
  • Updates to provider newsletters
  • Updates to provider manuals
  • Adding language to provider remittance advice advising no member liability
  • Adding language to member ID cards

CMS also reminded plans the Complaint Tracking Module (CTM) was updated to distinguish QMB complaints from other complaints. MA plans have historically struggled to ensure QMB members are not balance-billed. These are some of our most vulnerable members – they have very limited resources and many obstacles. It is critical MA plans do everything they can to ensure inappropriate provider billing is not an additional item these members have to face.

Gorman Health Group understands the challenges of correctly classifying beneficiaries. If you need help in educating your staff or evaluating your systems to see where improvements are possible, we are here to help. We all want to make a positive impact on our members’ lives – ensuring QMBs’ cost sharing is handled appropriately is a great place to start.




Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

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Julie Billman
Julie Billman

Julie Billman is Senior Vice President of Operational Performance & Provider Strategies at Gorman Health Group (GHG). In this role, health plans look to her to improve operational functions, maximize plan revenue, and educate plan staff to understand and own the Medicare requirements that govern their functions. Read more

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