Medicare Watch

QMBs Protected from Balance Billing

This month, the Centers for Medicare and Medicaid Services (CMS) released a new informational bulletin reminding state Medicaid agencies that those eligible for the Medicare Savings Program, Qualified Medicare Beneficiary, also known as QMB, cannot be “balance billed.” In most states, to qualify for QMB, an individual’s income must be at or below 100% of the Federal Poverty Level (FPL). In addition, while some states have eliminated asset tests, most states have asset limits that restrict eligibility.

Due to the protection against balance billing that the QMB program offers, Medicare providers are prohibited by law from billing QMBs for any Medicare cost-sharing, including deductibles and coinsurances or co-payments. Billing QMBs for these out-of-pocket costs is one kind of “balance billing.” Unfortunately, not all doctors and hospitals are aware of this policy, especially those providers who do not accept Medicaid.

The memo released by CMS explains how state Medicaid agencies process QMB claims. In addition, it includes recommendations on how to improve the claims process, in order to prevent the prevalent problem of providers inappropriately billing QMB beneficiaries for cost-sharing. The recommendations advise that state Medicaid agencies offer separate enrollment forms for QMB providers who do not accept Medicaid. For states that pay for Medicare cost-sharing on behalf of QMBs, doctors must submit the claim to a state Medicaid office to receive payment. Providing a QMB-only application would allow doctors who are not enrolled in Medicaid to still submit claims to Medicaid for QMB patients. The memo also suggests that states provide guidance to QMB providers, making clear that balance billing QMB patients is prohibited by law. In addition, it recommends that states explain guidelines on Medicaid provider enrollment and billing processes to QMB providers.

CMS’s bulletin also emphasizes that QMB providers have an obligation to enroll themselves in state payment systems, and it advises these providers to contact their state Medicaid agencies directly for more information how they can submit claims and receive payments.

This memo comes on the heels of an article that CMS released in the fall to providers, which explained rules regarding QMB billing.

Read the Medicare Learning Network (MLN) Matters article on balance billing QMBs.

Read the CMS Informational Bulletin to State Medicaid Agencies.

Report Explores How to Keep ACOs Accountable

This month, Families USA released a new report that aims to help advocates identify how to keep Accountable Care Organizations (ACOs) accountable to patients. The report, “Putting the Accountability in Accountable Care Organizations: Payment and Quality Measurements,” describes different ACO payment and quality measurement options. An ACO is a group of health care providers that agrees to be held financially responsible for not only improving health care quality for patients, but also for lowering costs across care settings. These settings can provide acute, post-acute, long-term care, or behavioral and mental health care services.

Payment options include a “shared savings model,” where doctors continue to be paid on a fee-for-service basis, but share in savings to the patient’s health insurer if they lower expenditures while still achieving high ratings on certain quality measures. Another option is a modified shared savings model that requires providers to assume some risk, as ACOs would be penalized for increased patient care costs. The brief also discusses the “capitation model,” where an insurer provides a set payment amount to an ACO for each patient. If the cost of care is lower than the payment, providers can keep the difference; if the cost of care is higher, providers must absorb the balance. Currently, the ACO model under construction in Medicare, also known as the Medicare Shared Savings Program ACO, employs the shared savings model.

Measuring quality of care is also an integral part of the ACO model, because in many cases, payment will be based on how an ACO scores on sets of health quality measures. The report discusses how not all quality measures are equal, as different quality measures represent different aspects of care. For example, some quality metrics measure outcomes, while others evaluate processes. The brief emphasizes the importance of patient experience measures, which in some cases may not be clinical, but are conclusive in determining patient satisfaction and engagement in their care.

Ultimately, the report suggests that the best way to hold ACOs accountable is to ensure that there is a strong link between payment and quality measurement, that payment incentives are enough to encourage providers to improve the way they deliver care, and that the right combination of quality measures is used to reflect actual improvements to care.

Read Families USA’s paper, “Putting the Accountability in Accountable Care Organizations: Payment and Quality Measurements.”

Medicare Reminder

Medicare will help pay for your home care if all of the following are true:

• You are homebound, meaning it takes a considerable and taxing effort to leave your home;
• You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care as little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy;
• Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound, need intermittent skilled care, that a plan of care has been created for you, and that a doctor regularly reviews it. As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive it or within 30 days after you have already started receiving it; and
• You receive your care from a Medicare-certified home health agency.

Learn more about requirements for Medicare coverage of home health care at www.medicareinteractive.org.

Spotlight

Forget Dear Abby—sign up for Dear Marci, your trusted source for Medicare answers. Dear Marci is Medicare Rights’ biweekly e-newsletter, designed to keep people with Medicare, their caregivers and the professionals serving them informed about health care benefits, rights and options for older Americans and people with disabilities.

Read the latest issue and sign up to receive Dear Marci.