• Billing for Patients with Dual-Eligibility Status


    Practices should consider whether they ought to be paid in full from both Medicare and Medicaid for patients with dual eligibility, meaning they have both Medicare Part B and Medicaid benefits.

    Dual-eligible patients who fall under the Qualified Medicare Beneficiary (QMB) assignment receive Medicaid assistance in paying for Medicare’s premiums, deductibles, coinsurance and, if applicable, copays. Therefore, billing the patients with QMB status is prohibited.

    As Medicare continues to see erroneous billing to patients with QMB status, the agency instructed each Medicare Administrative Contractor to issue letters to providers who violate this program policy. Physicians are to refund any current or previous billing to these patients. (An example of a cover letter for affected QMB individuals is available in the MLN Matters Article MM9817)

    Other programs under Medicare include:

    • Specified Low-Income Medicare Beneficiary (SLMB) program, and
    • Qualifying Individual (QI) program

    Qualifying patients receive assistance in paying their Medicare Part B premiums and may still have out-of-pocket expenses. Always follow the remittance advice from the payers as it will clearly state when a patient can and cannot be billed.

    For additional information see the CMS article Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs.