Medicare providers are prohibited from billing Qualified Medicare Beneficiaries (QMBs) for any Medicare co-payments or deductibles. This includes most dual eligibles. However, the problem of improper billing persists.
Decision in Alexander v. Price Means Medicare Patients Could Gain Right to Appeal Placement on “Observation Status” and Avoid Large Medical Bills
August 1, 2017 – Eighty-four-year-old Nancy Niemi of North Carolina was hospitalized for 39 days earlier this year after her doctor sent her to the emergency room. It took weeks to stabilize her blood pressure and she experienced serious complications. But unbelievably, Ms. Niemi was categorized as an outpatient on “observation status” for her entire hospitalization, and she therefore lacked the three-day inpatient stay Medicare requires for coverage of her subsequent, very expensive care at a nursing home. Ms. Niemi’s son tried to help her challenge her lengthy placement on observation status, but Medicare does not allow beneficiaries to appeal this issue. She still owes thousands of dollars to the nursing facility. However, due to the federal court decision issued July 31, 2017, she is now a member of a nationwide class of hospital patients who may gain the right to appeal their placement on observation status.
Senate leadership has announced that they will no longer move forward with the Better Care Reconciliation Act (BCRA) of 2017. Instead, they seek to proceed to a vote to immediately repeal the Affordable Care Act, and delay replacement to a later date.
While we are relieved that the BCRA, and its unprecedented cuts to Medicaid, is off the table, repealing the ACA remains a terrible idea that would harm older adults—especially in the absence of a meaningful replacement bill.
MSPs currently reach over 7 million people with Medicare. Many are too poor to afford Medicare but do not qualify for other Medicaid programs. This issue brief discusses how the program is structured and administered and outlines how cuts in Medicaid could force cuts to the program. Read More
Below is a statement from Justice in Aging Executive Director, Kevin Prindiville
“This new Congressional Budget Office (CBO) report shows that by 2026, 23 million Americans who previously had coverage will be uninsured. A disproportionately large number of the newly uninsured will be people between 50 and 64, whose premiums will skyrocket. For example, a single 64-year old with an income of $26,500 would have to pay a staggering $13,600 a year in premiums, more than half of what he has available to live on. That, compared to $1,700 a year under the Affordable Care Act, is an increase of more than 800%. Additionally, in states that waive consumer protections, older adults and others will see out-of-pockets costs rise sharply as plans provide skimpy coverage and can impose annual and lifetime limits.”
Below is a statement strongly opposing Trump’s 2018 budget from Kevin Prindiville, Executive Director of Justice in Aging:
“President Trump’s 2018 budget is an attack on the millions of older adults who already live on meager incomes and struggle to pay their rent, buy food, and meet their health needs. The budget imposes massive cuts to Medicaid, Social Security, and other critical programs that many older adults rely on for their health and economic security.”
Ensuring that Qualified Medicare Beneficiaries (QMBs) are not illegally billed for Medicare costs requires improvements on many fronts. One important piece is better identifying QMBs and informing both QMB consumers and their providers that they are subject to billing protections. Justice in Aging is pleased to share two new important resources contributing to that effort.
QMB Identification Survey
The new issue brief, authored by legal services attorney Peter Travitsky, looks at practices in 13 states in identifying QMBs. It finds that, although several states provide no QMB identification cards, others offer examples of best practices to ensure that QMB consumers and their providers know their protected status. The survey was supported by a post-fellowship grant from the Borchard Foundation Center on Law and Aging.
Incorporating QMB protections into Medicare notices
In October 2017, the Medicare program will be rolling out revised Medicare Summary Notices (MSNs) to QMB consumers and revised remittance advice notices to providers. On both notices, for each covered service, a notation will show that the individual is a QMB and that the co-insurance responsibility for each service is zero. To prepare providers for the revised system, CMS released a new Medicare Learning Network Matters article, Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System. As the new system is implemented, the article will be a useful tool for advocates to share with providers and their billing departments.
Visit the improper billing webpage, where you can find many more resources including a toolkit that with model letters to providers, an issue brief on recent improvements in QMB reporting and enforcement, recordings of past webinars on QMB billing and other valuable tools, including an improper billing tracking form that you can use to report instances of improper billing to inform our advocacy.