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Advocates, CMS Warn Providers About Continuing Medicare ‘Balance Billing’

CMS recently issued a report on the practice of “balance billing” — under which health care providers charge qualified Medicare beneficiaries (QMBs) a share of the cost of care, such as copayments.

That practice is illegal, CMS officials said.

Seniors and people with disabilities are considered QMBs if their incomes are less than federal poverty level and they have limited assets. States are required through Medicaid to cover some of the QMBs’ Medicare Part B premiums and the per-service cost-sharing, such as copayments.

“However, federal statute allows states to limit reimbursement by paying the ‘lesser-of’ Medicaid or Medicare rates [to providers], and most do,” the CMS report said. “As a result, the existing financing mechanism often means the provider must forgo the cost-sharing amounts.”

Providers are not allowed to collect any cost-sharing from QMB enrollees, by law.

“An unintended consequence of this policy may be that providers limit their patient pool to non-QMB enrollees,” the report said, “thereby having the effect of reduced access to routine health care among QMB enrollees.”

Denny Chan, staff attorney for Justice in Aging, a not-for-profit senior advocacy organization, said the practice is widespread and the law is simple:

“All Medicare physicians, providers and suppliers who offer services and supplies to QMBs must be aware that they may not bill QMBs for Medicare cost-sharing,” Chan said in a written statement. “This includes deductible, coinsurance and copayments, known as balance billing.”

“[We] applaud CMS for highlighting the stories of beneficiaries who are illegally balance billed and for providing detailed data and research to explain this problem,” Justice in Aging officials said in a statement. “As CMS, Justice in Aging, and advocates across the country work to end balance billing, the information in this report is an invaluable tool for understanding the problem.”

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