Are You Familiar with Qualified Medicare Beneficiary (QMB) Billing Obligations?
Qualified Medicare Beneficiary (QMB) is a program for patients that have Medicare Parts A and B coverage and qualify for additional coverage through Medicaid. This program assists low-income individuals with Medicare premiums and cost-sharing (copay coverage).
Providers, including pharmacies, are prohibited …
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from charging QMB patients any Medicare cost-sharing/copay. If pharmacies submit a COB claim to Medicaid and a Medicaid copay remains, that is allowed to be collected. Pharmacies must be aware that many state Medicaid programs will reject a COB claim, or the reimbursement on the claim will be set at $0. Regardless of Medicaid’s rejection or reimbursement, the pharmacy is not allowed to charge the patient the Medicare cost-share/copay.
Pharmacies are most likely to encounter these situations when a dual eligible patient has a Medicare Advantage Plan (MAPD) and you are billing for Part B covered items like diabetic test strips, continuous glucose monitor supplies, or nebulizer drugs. Pharmacies may see a claim response of “Benefit Stage Qualifier (BSQ) 51” in NCPDP D.0 field 393-MV to alert you that items were covered under the Part B benefit and that balance billing is prohibited.
Pharmacies are very aware of PBM implications for waiving copays; however, this is an exception. By refusing to fill a QMB prescription or charging the patient a copay, you may be in breach of your Provider Agreement. This can result in PBM investigations and even Cease & Desist notifications.
PAAS Tips:
- Refer to the Medicare MLN Fact Sheet from October 2024 for more information
- Educate staff to be on the lookout for BSQ 51 response messages when billing for Part B covered items to patients with MAPD plan
- If patient states they are a QMB but the claim system does not provide BSQ 51 message, then follow up with the MAPD plan or the state Medicaid program
- Pharmacies that receive an investigation notice or Cease & Desist, contact PAAS National® immediately for assistance
I attended Madison College in nearby Madison, WI (PAAS headquarters are in the Madison suburb of Stoughton). Prior to coming to work at PAAS, I worked as a Certified Pharmacy Technician in a retail setting for 25+ years. Pharmacy has been my life’s work.
Helping our members have a successful audit experience is very rewarding. Celebrating with them, when PAAS often helps generate positive post-audit results, is the best part of my work.
