In Medicare, the term improper billing refers to a provider inappropriately billing a beneficiary for Medicare cost-sharing. Cost-sharing can include deductibles, coinsurance, and copayments. Federal law prohibits providers from billing people enrolled in the QMB program for any Medicare cost-sharing. This means that if you have QMB, Medicare providers should not bill you for any Medicare-covered services you receive.
More specifically, if you have QMB and are enrolled in Original Medicare, you should not be billed when receiving a Medicare-covered service from either:
- A participating provider: a provider who agrees to always take assignment, meaning they accept Medicare’s approved amount for health care services as full payment.
- A non-participating provider: a provider who accepts Medicare payment but has not agreed to take assignment in all cases.
If you have QMB and are enrolled in a Medicare Advantage Plan, you should not be billed when receiving a plan-covered service from in-network providers, as long as you meet your plan’s coverage rules, such as getting prior authorization to see certain specialists.
To protect yourself from improper billing, be aware that:
- Original Medicare and Medicare Advantage providers who do not accept Medicaid must still follow improper billing protections and cannot bill you
- You keep your improper billing protections even when receiving care from Medicare providers in other states (Note: you can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider)
- You cannot choose to waive these protections and pay Medicare cost-sharing, and a provider cannot ask you to do this.
Remember that if you have QMB, the Medicare providers you see must accept Medicare payment and any QMB payment as the full payment for any Medicare-covered services you received. Providers who violate improper billing protections may be subject to penalties. If you are having issues with a provider who continually attempts to bill you, or if you have unpaid cost-sharing bills that have been sent to collection agencies, call 1-800-MEDICARE or contact your Medicare Advantage Plan.
Note: some states may impose Medicaid copays for certain Medicare-covered services. Medicare and Medicaid should pay the majority of the cost, leaving you a nominal, or small, copay. Contact your local Medicaid office to learn more about Medicaid copays in your state.
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