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A recent Centers for Medicare & Medicaid Services (CMS) report, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), revealed several access to care problems for low-income Medicare beneficiaries enrolled in the QMB program.

The report analyzed two studies focused on access to care for low-income beneficiaries. The first study utilized qualitative interviews with beneficiaries to examine the illegal provider practice of “balance billing” (providers’ billing and collecting cost-sharing from QMB enrollees for Medicare-covered services); the second study, the quantitative study, investigated whether there is an association between state reimbursement policies for cost-sharing and health service utilization in this population.

QMB Program

The QMB Program provides payment of Medicare Part A monthly premiums (when applicable), payment of Medicare Part B monthly premiums and annual deductible, and payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B.

In order to be eligible for the QMB program, an individual must be eligible for Medicare Part A (even if not currently enrolled). The individual’s monthly income must be at or below 100% of the annual Federal Poverty Level [FPL x 1]. The Federal Poverty Level is announced each year, and the income eligibility level for the Qualified Medicare Beneficiary program changes to reflect that figure each April. For 2015, the individual monthly income limit is $1,001; the married couple monthly income limit is $1,348. The individual resource limit is $7,280; the married couple resource limit is $10,930.

Qualitative Study: Balance Billing

People with QMB are excused, by law, from paying Medicare cost-sharing. Providers are prohibited from charging them. All cost-sharing (premiums, deductibles, co-insurance and copayments) related to Parts A and B is excused, meaning that the individual has no liability.  The state has responsibility for these payments for QMBs regardless of whether the particular service is also a Medicaid-covered service.

Despite this prohibition, the CMS study found that providers illegally balance-billed participants for Medicare cost-sharing on a regular basis. Due to a lack of information, confusion regarding the system, or concern over outstanding bills, most QMB enrollees participating in the study paid these bills. Additionally, participants reported that unpaid bills were submitted to collection agencies. Another finding in the study was that participants experienced challenges with the appeals process. The study also found that beneficiaries were dissatisfied with service coverage, particularly for Durable Medical Equipment (DME).

Quotes from the CMS Study Participants on Balance Billing

  • “I received two bills that I know I should not have received. I was sick and I needed the care, so I just paid them.”
  • “My medical bills never seem to be right. I often get bills that I should not be receiving. I get so frustrated fighting the system that I just pay them. I am a master at going without things that I need.”
  • “I collapsed so my neighbor called an ambulance. I got a bill for $595. I thought my insurance would pay for it. Bills for the ambulance kept coming. I could not pay. Then the bill collectors started to call me day and night. I called Medicare and they told me to go to the local lady [SHIP counselor]. I went to the lady and she was so helpful. I told her that CVS won’t give me my medication unless I pay $53.00. She told me I shouldn’t pay anything for the ambulance and I shouldn’t pay anything for my medications. She helped me file an appeal.”
  • “Every time I visit the doctor I get a bill for $15.27. I know I should not be receiving these, but I don’t want to ‘rock the boat’. The doctor is in walking distance, so I don’t need to take public transportation. That saves me a lot because my income is only $329 a month. I ultimately do not know what I should and shouldn’t pay? I really feel anxious. I do not know what is going to happen with my health care. My food stamps were just cut. So you never know.”

Quantitative Study: State Cost-Sharing Policies

A provision in the Balanced Budget Act of 1997 (BBA), gave states the option to reimburse Medicare cost-sharing to providers for services provided to dually eligible beneficiaries at their lower Medicaid rate, rather than the full Medicare rate. Federal law also authorizes states to pay at the Medicare rate even if that rate is higher than what the state would pay for a non-dual eligible on Medicaid. Under a BBA provision sometimes referred to as the “lesser-of” policy, if the Medicare share (80 percent of the Medicare allowable amount for most Part B services) is more than the state’s Medicaid rate for the same service, the state need pay nothing. Since the enactment of the BBA, courts have held, even in cases that predated the BBA, that states may reimburse at the lower of the two reimbursement rates. Thus, dually eligible beneficiaries are treated as Medicaid rather than Medicare beneficiaries, with respect to provider reimbursement. Studies have found that these payment reductions have led to reduced utilization and provider access problems.

The CMS report cited to previous research that found a direct association between the percent of cost-sharing paid by Medicaid and access to care, with reduced access to care in states that reimbursed providers at the lower rate. “The extent of the reductions in Medicaid cost-sharing payments proportionately lowered the odds that a dually eligible beneficiary would have an outpatient visit.”

The report stated “the lesser-of payment policy may have the effect of limiting access to primary, routine, and preventive care among QMB [plus and only] enrollees.” Citing a previous MACPAC study that found elevated use of safety net providers among beneficiaries in lesser-of states, the report also found slightly higher utilization of more acute care services, such as SNF stays, emergency department visits, and ACSC-related hospitalizations.” The fact that QMB enrollees were less likely to use office visits and hospital outpatient services, when compared to Medicare-only enrollees, in states that employed the “lesser-of” policy for reimbursement indicates that these state policies effectively limit access to essential care for beneficiaries. Consequently, QMB-only enrollees in lesser-of payment states were more likely to use emergency department and acute care services than Medicare-only enrollees.

According to the report, “An unintended consequence of this policy may be that providers limit their patient pool to non-QMB enrollees, thereby having the effect of reduced access to routine health care among QMB enrollees.” The qualitative and quantitative findings in the report “support the hypothesis that reduced coverage of cost-sharing reduces access to care for QMB enrollees.”

This study focused exclusively on three categories of services: 1) Outpatient Services (Office Visit Services, Hospital Outpatient Services, and Mental Health Services); 2) Inpatient and Institutional Services (Hospital Inpatient Services and Skilled Nursing Facility Services); and 3) Potential Downstream Indicators of Limited Access to Care (Emergency Room Services and Hospitalizations for Ambulatory Care-Sensitive Conditions (ACSC)).


The CMS report shows an alarming trend that low-income beneficiaries enrolled in the QMB program are frequently being illegally balance-billed, and that though they are not liable for the charges, many of the bills were sent on to collections if unpaid, and most beneficiaries actually paid. In addition, the CMS report found that QMB enrollees were less likely to use office visits and hospital outpatient services compared to Medicare-only enrollees in states that employed the “lesser-of” policy for reimbursement, thereby limiting access to essential routine and preventive care for beneficiaries. The report provides troubling information regarding access to care for low-income beneficiaries that underscores the need for continued advocacy efforts for this vulnerable population.

The full CMS report is available at:

Additional Information about Medicare Savings Programs is available at:

Additional information on balance billing is available at:

August, 2015 – K. Kertesz

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