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Balance Billing QMB and MQMB Clients

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Note: This article applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, and reimbursement.

Reminder: All Medicare physicians, providers, and suppliers who offer services and supplies to Qualified Medicaid Beneficiaries (QMBs) or Medicaid Qualified Medicare Beneficiaries (MQMBs) must not bill QMBs or MQMBs for Medicare cost-sharing. This includes deductible, coinsurance, and copay.

While providers are generally allowed to bill Medicaid clients under certain circumstances in accordance with 1 Texas Administrative Code (TAC) 354.1131, and as described in the Texas Medicaid Providers Procedures Manual, Provider Enrollment and Responsibilities, (Vol. 1, Provider Handbooks) Section 1.6.9, Billing Clients, QMB and MQMB clients are an exception to this rule as federal law prohibits Medicare providers from balance-billing QMB and MQMB clients for Medicare cost-sharing.

This federal policy on balance-billing QMB and MQMB clients applies regardless of whether the provider is enrolled as a Medicaid provider. In accordance with section 1902(n) (3) (B) of the Social Security Act, providers who are enrolled in Medicare cannot accept QMB or MQMB clients as “private pay” to bill the client directly. Regardless of a signed private pay agreement, providers cannot bill QMB or MQMB clients. QMB and MQMB clients have no legal obligation to make further payment to a provider for Part A, Part B or Part C cost-sharing.

Since QMB and MQMB clients cannot legally be held liable for Medicare cost-sharing, Medicare providers must submit a claim to TMHP for the Medicare deductible, coinsurance, or copay. Medicare providers who are not already enrolled with the Texas Medicaid Program must enroll to be considered for claims reimbursement. If a Medicare provider does not accept Medicaid, they cannot bill a QMB or MQMB client for Medicare cost-sharing, even if they choose not to enroll in Medicaid.

Per the Centers for Medicare and Medicaid Services (CMS), providers who inappropriately bill QMB/MQMB clients for Medicare cost-sharing are subject to sanctions. For more information, see MLN Matters Article Number SE1128.

For more information, call the TMHP Contact Center at 1-800-925-9126.