Qualified Medicare Beneficiary (QMB) Program

Federal law prohibits Medicare providers (including pharmacies) from billing QMB patients for cost sharing amounts related to Medicare Part A or B covered items. QMB patients bare no legal obligation to pay cost sharing for these items – cost sharing amounts must only be billed to Medicaid. If there is a copay after billing Medicaid, pharmacies may collect this amount.

Pharmacies are most likely to encounter these situations when a dual eligible patient has a Medicare Advantage Plan (MAPD) and you are billing for Part B covered items like diabetic test strips, continuous glucose monitor supplies, or nebulizer drugs. Pharmacies may see a claim response of “Benefit Stage Qualifier (BSQ) 51” in NCPDP D.0 field 393-MV to alert you that items were covered under the Part B benefit and that balance billing is prohibited.

Please note that the QMB Program and prohibitions on collecting copays apply to Part B covered items only; pharmacies must continue to collect copays for Part D covered drugs.

PAAS Tips:

• Be on the lookout for BSQ 51 response messages when billing for Part B covered items to patients with MAPD plan
• If patient states they are a QMB but the claim system does not provide BSQ 51 message, then follow-up with the MAPD plan or the state Medicaid program