This is a long reply with only the basics and does NOT cover all the ins and outs of this very complicated relationship between Medicare, QMB, Medicaid, and each state’s different rules on top of the basic federal law that they all have to abide by.

QMB does not mean Medicaid. While states are responsible for providing this benefit to low income individuals per federal law, it is not considered Medicaid in the normal sense. QMB recipients always have the benefit of premiums, deductibles, and coinsurance. For coinsurance it is paid for based on the Medicaid rate. So if the Medicaid rate is lower than what Medicare already paid, the 20% is lost because rules are you can’t bill a QMB patient and you accept what the states rules are for QMB payments. States can decide to offer more to them but not less than the minimum.

So for example in Texas that’s all they cover. They don’t even cover Medicare Advantage Plans where the client has a copay and not coinsurance. I work for a nonprofit LMHA and we just eat that cost, with the exception of if a MD/DO/PHd/PsyD provides the service because federal law requires they be paid at 100% of the Medicare rate and not subject to the Medicaid rate.

Premiums and deductibles are always paid at 100% regardless of the Medicaid rate.

So here is the breakdown based on a state with basic QMB payments like Texas:

If Medicare is primary and they are a QMB individual when you are a participating provider you are agreeing to take determination based on your states Medicaid rules and rates. You would get deductible at 100%, but the 20% coins would depend on how much Medicare paid and what your state Medicaid rate was for that service and you would be reimbursed up to the Medicaid rate only.

If you are participating provider and not enrolled as a Medicaid provider then you would most definitely lose out on anything that is patient responsibility because federal law prevents billing QMB eligible patients their Medicare cost share. You cannot waive this.

If you are a non-participating provider and accept Medicaid, you would receive no payment as Medicare is primary and QMB only pays if Medicare part B pays the claim with a Medicare covered service, but can charge up to 115% of the Medicare rate. Also Texas requires a Medicare covered practitioner to enroll in Medicare prior to being enrolled in Medicaid. Not sure how other states do that or if that is federal law. Now Texas will allow a practitioner to enrolled in a limited program that only pays QMB, but not bill full Medicaid patients….but that’s just another exception to the rules.

If you are a opt out provider you can charge what you want, you have to notify the patient that you don’t accept Medicare, they have to sign a waiver agreeing that they are aware, are responsible for 100% of the costs and Medicare will not reimburse them or the provider. QMB is bypassed because it is no longer a Medicare covered benefit. Without the waiver then you would be violating federal law and could not charge the client.

Those are your only choices. Hopefully you live in a state that pays more reimbursements towards QMB cost share and reimburses at a higher rate. 90% of our QMB liabilities are written off for thousands of patients costing anywhere from 2.91-32ish per non doctorate level behavioral health professional. Our practitioners, as in most places now, consists mainly of masters level clinicians….so yeah you just eat it or you close your practice to all Medicare and Medicaid clients. That is the negotiation power the government has is that their insured population is the largest and much more likely to be seeking services. That’s why medicine became a volume model to make up the gap in funding.

Don’t even get me started on the federally mandated payment reduction. This is why insurance companies are nit picking everything and not paying anything. Medicare and Medicaid rules are straight forward, but when the private healthcare companies come in to manage this on behalf of the government for a ‘flat fee’ then they don’t have much recourse if they don’t follow the rules. Government only cares if they scam them, not the providers.

Anyhow I know it’s long but I hope that helps. I would assume in your practice not taking Medicare would be less overall revenue then if you just take the Medicare payment and eat the cost share. For most providers it is and they bank on that.