Aetna Balance Billing Notice for Medicare Beneficiaries

March 2018 ~

Aetna has issued a notice reminding providers and billing professionals that Medicare beneficiaries under the Qualified Medicare Beneficiary (QMB) program should not bill for cost sharing (balanced billing).

State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. But federal law allows states to limit provider reimbursement for Medicare cost sharing under certain conditions. Dually eligible individuals may qualify for Medicaid programs that pay Medicare Part A and B premiums, deductibles, coinsurance and copays to the extent the state Medicaid plan provides.

Under the QMB program for Medicare beneficiaries, providers cannot charge for cost sharing.

All Original Medicare and Medicare Advantage providers (not just those that accept Medicaid) must follow the balance billing rules. Medicare providers must accept the Medicare and Medicaid payment (if any) in full for services given to a QMB beneficiary. Providers cannot balance bill these members when they cross state lines for care, no matter which state provides the benefit.

Medicare providers who don’t follow these billing rules are operating against their provider agreement. And they may be subject to sanctions.

For more information, refer to the Medicare-Medicaid General Information page and the Dual Eligible Beneficiaries Under Medicare and Medicaid booklet.

Source(s): Aetna OfficeLink Updates^™ All Regions;