Ambulance Partner Meeting Questions and Answers

To: Ambulance Partner Meeting Members
From: Palmetto GBA Provider Outreach and Education (POE)
Date: October 25, 2024

Questions for Response

General

1. Question: In Virginia, the Medicaid system has a program called Qualified Medicare Beneficiary (QMB). This program helps to cover the cost of Medicare copays and deductibles, as well as premiums. However, no actual benefits are provided via the Medicaid system. Because of the structure of the Medicaid system here, all patients are assigned an MCO to manage their Medicaid policy, even those in the QMB program. However, because no benefits are available through the Medicaid QMB program, no benefits are available through the MCO either. The problem is that Medicare, when billed, denies claims for those patients, as they consider the MCO to be primary to them, despite the patient not having benefits in that program. 

So Medicare and the MCO will both deny any claim sent. We are unable to bill the patient under regulations in Virginia’s DMAS programs that prevent it. Leaving us with no payer unless the transport was booked via a facility who agrees to pay, but that is not the correct payor. Consider holding hospitals responsible for discharge transportation. It does not make sense. 

We are unsure if this is a problem with how the Coordination of Benefits is occurring related to the Medicaid QMB program, or if the MCO’s themselves are enrolling the patients incorrectly. Repeated attempts to seek assistance from DMAS have not resulted in any clear answers. We would appreciate any guidance and assistance that Palmetto can provide on how to get these claims processed, as in most cases Palmetto appears to be the correct payer of these claims.

Answer: The QMB eligibility group is a Medicaid eligibility group through which states pay Medicare premiums and cost-sharing for certain low-income Medicare beneficiaries (QMBs). The QMB eligibility group is one of the Medicare Savings Programs.

Federal law prohibits all Original Medicare and Medicare Advantage (MA) providers and suppliers (not only those that accept Medicaid) from billing QMBs for Medicare Part A and Part B cost-sharing. Even if you don’t receive full payment from Medicaid, you can’t bill a QMB. See the Prohibition on Billing Qualified Medicare Beneficiaries Fact Sheet (PDF) and MLN006977 – Beneficiaries Dually Eligible for Medicare & Medicaid Fact Sheet (PDF) for additional information on the QMB eligibility group and dual eligibility.

There are several different entities or contractors involved in the question above, and it is important to note that Medicare Administrative Contractors (MACs), such as Palmetto GBA, are separate from the Medicaid program, individual states, Medicare Advantage plans such as Managed Care Organizations (MCOs), and the Benefits Coordination & Recovery Center (BCRC).

State regulations vary from state to state and are not determined or administered by Palmetto GBA. 

The BCRC consolidates the activities that support the collection, management and reporting of other insurance coverage for beneficiaries. The BCRC takes actions to identify the health benefits available to a beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims. The MACs, Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment. These entities help ensure that claims are paid correctly when Medicare is the secondary payer.

These actions are referred to as Coordination of benefits (COB). COB allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).  

Palmetto GBA uses information on the claim form, electronic or hardcopy, and in the CMS data systems to avoid making primary payments in error. Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as a primary payer and will deny the claim and advise the provider of service to bill the proper party.

COB relies on many databases maintained by multiple stakeholders including federal and state programs, plans that offer health insurance and/or prescription coverage, pharmacy networks, and a variety of assistance programs available for special situations or conditions.

For patients that have both Medicare and Medicaid and no other insurance, Medicare is the primary payer. However, Medicare records may not reflect the patient's current insurance status. If you find that there is a discrepancy between Medicare records and the patient's current insurance status, call the MSP Contractor at 855–798–2627 or TDD/TYY 855–797–2627. The MSP Contractor may also need to speak to the patient. However, providers are permitted to call. See CMS' Coordination of Benefits website for additional information on COB.