Knowledge Base Article

What’s the difference between nice and kind? Nice is treating others respectfully while kindness involves a deeper caring for others. A recent television commercial presents that it is related to a particular type of snack bar. If you go for the snack bar analogy, what about healthcare coverage? One might say that Medicare coverage for the elderly is a nice program, and that Medicaid for those with limited income and resources is a kind program. I suppose that makes dual eligibility programs both nice and kind.

Some hospital patients will have both Medicare and Medicaid medical coverage. Certain qualified Medicare beneficiaries (known as dual eligible or QMB patients) meet criteria to get help with their Medicare premiums and cost-sharing. According to CMS’s QMB Program webpage, “In 2016, 7.5 million people (more than one out of eight people with Medicare) were in the QMB program.” Because of this program, providers, including hospitals, must bill the state Medicaid program for the patient’s Medicare deductible and co-pays. Patients in the QMB program are not legally obligated to pay providers for any Medicare cost-sharing, even if Medicaid does not pay the entire amount. The webpage noted above also reports that historically there has been confusion and billing errors related to the QMB program. I can certainly understand – dealing with Medicare rules by themselves is challenging enough – the challenge doubles when there are two government payers. I recommend billers mark the QMB webpage for future reference. It offers numerous resources and information about the QMB program, such as a list of QMB Frequently Asked Questions.

One new question and answer in the QMB FAQs deals with billing limitations and special instructions when an Advance Beneficiary Notice (ABN) is given to a dual eligible patient. An ABN is given to a Medicare patient when the item or service being provided is expected to be denied by Medicare as not reasonable and necessary (medical necessity denial). The ABN notifies patients they will be financially liable for the service and allows them the option to elect to have the service or not. When presenting an ABN to a dually eligible Medicare/Medicaid patient, the provider:

• Directs the patient to select Option 1, which requires a claim be submitted to Medicare for an official decision on payment. (Note: This is the only time a provider may direct a patient as to which option to select.)
• CANNOT require payment from the patient at the time of the service. In fact, the provider cannot bill the patient until the claim is adjudicated by both Medicare and Medicaid.
• Submits a cross-over claim to Medicaid if Medicare denies payment.
• Can shift liability to the patient based on Medicare policy and state laws if the claim is denied by Medicare as not medically necessary and if coverage is denied by Medicaid (or not paid for other reasons).

Dual eligible patients are also liable for Medicare statutorily excluded services if the patient or the services are not covered by Medicaid. Although an ABN is not required to be given for statutorily excluded services, it is a nice courtesy to ensure patients are aware of their potential financial liability. Or maybe even kind. The world certainly needs more niceness and kindness.