What is a Qualified Medicare Beneficiary?

Medicare’s new program, Advanced Primary Care Management (APCM), moves away from time-based tracking and focuses on reimbursement based on a patient’s risk level. The highest risk level is covered under CPT code GPCM3 and focused solely on any patient who is a Qualified Medicare Beneficiary (QMB).

What is a Qualified Medicare Beneficiary?

As a type of Medicare Savings Program (MSP), the Qualified Medicare Beneficiary program offers state-funded support to low-income Medicare enrollees. Beneficiaries qualify by meeting predetermined income and resource limits.

The QMB program helps cover the following costs for eligible beneficiaries:

• Medicare Part A monthly premium
• Medicare Part B monthly premium
• Medicare Part B annual deductible
• Coinsurance and deductibles for healthcare services, such as care management services

Individuals enrolled in QMB are protected from certain provider billing. According to The Centers for Medicare and Medicaid Services (CMS), “Federal law prohibits Medicare providers and suppliers, including pharmacies, from billing individuals in the QMB group for Medicare cost sharing.   

Medicare beneficiaries enrolled in the QMB group have no legal obligation to pay Part A or Part B deductibles, coinsurance, or copayments for any Medicare-covered items and services.”

Some qualified Medicare beneficiaries are considered QMB Plus, which means that they meet all criteria for the QMB program but also meet all financial requirements to receive full Medicaid services. These enrollees can receive benefits through the QMB program as well as their state’s health plan.

Qualified Medicare Beneficiaries make up one of four types of MSPs

A Qualified Medical Beneficiary is one type of beneficiary, but there are three others that meet varying qualifications for Medicare Savings Programs, including:

• Specified Low-Income Beneficiary (SLMB)
• Qualifying Individual (QI)
• Qualified Disabled Working Individual (QDWI)

The chart below from the Medicaid and CHIP Payment and Access Commission’s (MACPAC) publication, Chapter 3: Medicare Savings Programs: Enrollment Trends, highlights the main differences among the MSPs, including Medicaid enrollment, dual eligibility type, income thresholds, and what types of Medicaid payments each beneficiary qualifies.

Source: Chapter 3: Medicare Savings Programs: Enrollment Trends. Medicaid and CHIP Payment and Access Commission (MACPAC), 2024.

Why does Advanced Primary Care Management focus on QMBs?

Medicare launched the APCM program in 2025 with three risk-based levels, as shown below. The third level is designated for QMB and QMB Plus beneficiaries who also meet the criteria for G0557 of having two or more chronic conditions. APCM does not pertain to the other three types of MSP beneficiaries–SLMB, QI, or QDWI.

*National average rate dependent on geographic factors. Check the Physician Fee Schedule for the latest information.

APCM focuses on QMBs because they encompass a high-complexity patient population within Medicare. People with QMB status frequently live with multiple chronic conditions and substantial social determinants of health challenges.

Because QMBs are considered the most vulnerable Medicare beneficiaries, CMS makes them a priority for proactive and coordinated care management services.

The APCM program supports QMBs in three ways:

As a high-risk population: It’s common for QMBs to have multiple chronic conditions as well as face barriers to accessing care due to financial constraints. APCM's comprehensive care approach bundles services that are well-suited for QMB needs.

Billing structure: APCM’s CPT codes reflect patient complexity, and the highest payment level is reserved for QMB patients with multiple chronic conditions. 

Focus on social determinants: APCM aims to address not just medical needs but also social risk factors impacting a QMB's health, such as access to transportation, housing, and nutrition. 

How to identify your QMB patient population

Primary care practices can identify Qualified Medicare Beneficiaries by directly asking patients about their eligibility for state Medicaid programs during intake or a Medicare Annual Wellness Visit.

Providers can use the following to confirm a beneficiary’s QMB status:

QMB enrollment cards: Many states have QMB program enrollment cards.

Medicare Summary Notices: Original Medicare beneficiaries with Part A and/or Part B receive this document every three months, providing details about all medical services or supplies billed to Medicare over that period.

Medicaid income thresholds: Check patient demographics against income thresholds set by the state Medicaid program. If a patient appears to qualify, they should be encouraged to provide proof of income to confirm their QMB status.

ThoroughCare enables care management for vulnerable patient populations

ThoroughCare provides intuitive digital tools and care coordination training that supports care management for the most vulnerable patient populations.

Encompassing the latest Medicare rules and rates, ThoroughCare enables fee-for-service programs through evidence-based standards, seamless workflows, and features to make compliant billing seamless.

With one platform, all of these care management programs are ready to be turned on simply by enrolling a patient in:

• Principal Care Management (1 condition)
• Chronic Care Management (2 or more conditions)
• Remote Patient Monitoring (standalone or combined with other programs)
• Transitional Care Management (30-day program)
• Behavioral Health Integration
• Annual Wellness Visits

Along with software, ThoroughCare provides clinical advisory services to empower teams with expert guidance and training in care coordination. Our clinical team can help you develop programs and optimize workflow.

Key questions answered

What is a Qualified Medicare Beneficiary?

A Qualified Medicare Beneficiary is a Medicare enrollee who meets predetermined income and resource limits. They receive state-funded assistance to help cover certain healthcare costs, including deductibles, premiums, and copays.

Why does Advanced Primary Care Management focus on QMBs?

The Advanced Primary Care Management program emphasizes QMBs because these beneficiaries represent a high-complexity patient population within Medicare. They are often living with multiple chronic conditions and facing significant social determinants of health challenges.

Because QMBs are considered the most vulnerable Medicare beneficiaries, Medicare prioritized proactive and coordinated care management services through the APCM program.