0865.000.00 Qualified Medicare Beneficiaries (QMB)

0865.035.25 QMB Benefits Guide

IM-06 January 20, 2012; IM-110 December 13, 2006; IM-138 November 21, 2005; IM-128 December 2, 2004

The pamphlet IM-4 (QMB) provides general information regarding benefits covered under the QMB program. This guide is intended to supplement that information. This guide explains which services are covered by QMB only, which are covered by MO HealthNet only, and which are covered by both. If the Eligibility Specialist is unable to determine if a specific service is covered by QMB, the Eligibility Specialist may call the MO HealthNet Division’s Participant Services Unit at 800-392-2161.

Note the following differences between QMB and regular MO HealthNet.

QMB pays. MO HealthNet pays.
Coinsurance and deductibles for all Medicare covered services. Coinsurance and deductibles for Medicare covered services to MO HealthNet providers.
The full charge for a Medicare covered service only if the individual’s deductible is not yet met. The full charge for MO HealthNet services not covered by Medicare.
As the secondary payer only. Medicare is always billed first. As the payer after all other third parties.
As the primary payer only if no other coverage is available.

The Medicare Part A and QMB Chart may be used to help explain benefits to the claimant and to determine what expenses to allow toward MO HealthNet spend down for individuals who are currently receiving QMB benefits. Do not allow any charges that are covered by both Medicare and QMB towards spend down.

The first two columns show general Medicare services and the corresponding coinsurance and deductibles for 2012 for Part A and Part B. The columns show who is responsible for payment for each type of services. For the services listed, only those charges in the “Participant Pays” column are allowable toward meeting MO HealthNet spend down for a QMB recipient.

The third column shows which types of providers are paid by MO HealthNet, which are paid by QMB, and which are paid by both. Some provider information on the listings is qualified by statements regarding specific services for which payment can be made. On this chart, allow toward MHN spend down for a QMB recipient expenses for services from providers paid by MO HealthNet only. (Do not count toward MHN spend down charges for those specific services identified as covered by QMB).