Federal Medicare Agency Releases Guidance That Will Help Low-Income Medicare Beneficiaries
Medicare Part D
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For years, Legal Aid has been working with federal and local Medicare advocates to protect low-income Medicare beneficiaries from improper charges by doctors and other providers.  We are delighted to announce that these efforts have culminated in newly released guidance from the federal Centers for Medicare and Medicaid Services (CMS) informing providers and state Medicaid agencies about these protections. 


Medicare is a federal health insurance program that provides coverage for elderly and disabled individuals with a work history.  The lowest income Medicare beneficiaries are also covered by Medicaid, which for them covers most Medicare costs and fills gaps in Medicare coverage.  Medicare beneficiaries with somewhat higher incomes are eligible for a less comprehensive District of Columbia program which supplements their Medicare benefits by covering Medicare premiums and co-payments for hospital and physician services and partially subsidizing prescription drug costs.  This program is called the Qualified Medicare Beneficiary, or QMB, program.

In its groundbreaking efforts to provide health coverage to its low income citizens, the District expanded income eligibility for the QMB program from 100 percent of poverty (about $900 per month for an individual) to 300 percent of poverty (about $2,700 per month for an individual) and eliminated asset limits.  Until now, however, many QMBs have failed to get the intended benefits because many providers have lacked understanding of QMBs’ rights. 

Billing protections 

The Medicare law prohibits any Medicare provider – regardless of whether the provider also participates with Medicaid – from collecting any co-payment from a QMB beneficiary (or a Medicaid beneficiary).  However, many medical providers are not aware of this provision of the law and quite often bill their Medicaid or QMB patients for costs not covered by Medicare. In several of Legal Aid’s cases, providers refused to cancel the charges without explicit guidance from CMS, which was difficult and time consuming to obtain.  We have heard about similar problems in other jurisdictions.

CMS guidance

Due in part to advocacy by Legal Aid and other local groups, including the Whitman-Walker Clinic Legal Program and the George Washington University State Health Insurance Counseling Project, as well as national groups, including the Center for Medicare Advocacy and the Health Assistance Partnership, last week, CMS released formal guidance memoranda emphasizing this billing prohibition.  The guidance also provides additional educational information to medical providers about the QMB program.  This explicit statement of our clients’ rights will help Legal Aid and other advocates enforce our clients’ rights to avoid unlawful charges and the resulting undue economic hardship. 

Contributed by members of Legal Aid's Public Benefit Unit:  Lucy Newton, Jennifer Mezey, Andrew Patterson & James Springer

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