What is a Qualified Medicare Beneficiary?

As a healthcare provider, you know that Medicare patients often face challenges with out-of-pocket costs. One program that directly impacts your billing process—and your patients’ financial well-being—is the Qualified Medicare Beneficiary Program, or QMB. In this video, we’ll explore what this program entails, who is eligible, and how to identify QMB patients.

With new Medicare programs like Advanced Primary Care Management (APCM) having a billing code focused solely on any patient who is a QMB, it's important to understand this qualification.

A QMB is a Medicare Savings Program that aims to help low-income individuals afford Medicare.  They are Medicare beneficiaries who also qualify for assistance from their state’s Medicaid program. They receive state funded assistance to help cover healthcare costs, including deductibles, premiums, and copays.

The QMB program helps cover several costs for eligible beneficiaries including:

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

Who is eligible for the QMB Program?

To be eligible, individuals must meet specific income and resource limits, which can vary by state. They must also be eligible for both Medicare and Medicaid to qualify for QMB.

The QMB program is administered by each state’s Medicaid agency.

Healthcare providers cannot charge QMB beneficiaries for Medicare cost-sharing amounts.

How do you 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, depending on the state
• A patient's Medicare Summary Notices
• And by checking patient demographics against Medicaid income thresholds set by the state 

Why do programs like APCM 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.