While the benefits afforded by the Medicare and Medicaid programs are held dear by many seniors, the complications connected to them are not. And recent research reveals that consumers, particularly seniors with low incomes, are most often caught in the crossfire between the bureaucracies of healthcare providers and government agencies. As a result, they are hardest hit by confusing application processes and wrongful billing practices. Hopefully, some recent administrative changes should help right those wrongs.

The Nitty Gritty on QMBs

Many billing problems have centered on Medicare Part A, which generally covers hospital care and a number of other types of long term care seniors may need, as well as hospice and home health services. The coverage is free for people 65 and older who have worked and paid taxes to Medicare for the required length of time, or who have a spouse who qualifies. It is also available to people who have few assets and low incomes — generally at or below the federal poverty limits — through the Qualified Medicare Beneficiary (QMB) program, which was established in 1988. Today, about 7.5 million people, or more than one out of eight people with Medicare, are enrolled in the program.

But the QMB benefits come wrapped in red tape.

In many cases, hopeful beneficiaries must file first for “conditional” Part A coverage through the Social Security Administration (SSA) — and then apply for QMB status at their state’s Medicaid office. Running this bureaucratic gauntlet is made even more difficult because in some states, the SSA application must be filed within a narrow window of time. Those states include Alabama, Arizona, California, Colorado, Illinois, Kansas, Kentucky, Missouri, Nebraska, New Jersey, New Mexico, South Carolina, Utah, and Virginia. In those 14 states, prospective applicants must apply for conditional Part A coverage between January 1 and March 31 of each year; QMB status can start no earlier than July 1, no matter how early in that window they apply.

The Bugaboo of ‘Balance Billing’

Once people qualify as QMB enrollees, healthcare providers are prohibited from charging them for the remaining portion of their bills that are not covered by Medicare — known as “balance billing.”

The Centers for Medicare & Medicaid Services (CMS) recently undertook a study to determine the truth behind the common complaint that providers are continuing the practice of balance billing. The results, published in “Access to Care Issues Among Qualified Medicare Beneficiaries (QMB),” is written mostly in Medicare-speak, but clearly confirms that the nefarious practice endures.

The report also makes the plainspoken finding that most participants simply pay the bills they receive. Some were unaware that the billing was illegal. Some were simply weary of doing battle over disputed charges. Said one senior: “I received two bills that I know I should not have received. I was sick and needed the care, so I just paid them.” And another: “I often get bills that I should not be receiving. I get so frustrated fighting the system that I just pay them. I am a master at going without things that I need.”

A good share of the billing mistakes made are likely unintentional. According to a recent study by Justice in Aging, for example, one simple but enduring problem is that healthcare providers often have trouble identifying which patients are QMBs. Patients are currently issued a confusing array of insurance cards issued by state, federal, and private insurance sources to show their insurance status; they may or may not identify the carrier as a QMB. Some states and local governments — notably, in the District of Columbia, Maryland, North Carolina, and Ohio — have taken steps to issue cards that specifically identify the cardholder as a QMB.

Steps in the Right Direction

In better news, the various agencies involved have made a couple important changes intended to help clamp down on the bad billing practices, both by clarifying instructions to administrators and issuing straightforward bills to consumers.

Revised notices for consumers.The Centers for Medicare & Medicaid, the agency responsible for administering those benefit programs, recently announced that beginning in July of 2018, both QMBs and RAs will receive revamped MSNs. That’s Medicare-speak for notices that promise to be “provide clarity,” though the promise at first might not inspire much hope. In human-speak, the change means that the notices sent to beneficiaries every three months will indicate they owe no co-insurance for each itemized service covered by Medicare; notices sent to the healthcare providers will also show the beneficiaries them owe nothing for those services.

The new approach applies to all services received from July 2, 2018 onward. A warning on the newly-formatted notices urges consumers: “Be Informed!” It goes on to underscore that providers and suppliers who accept Medicare are not allowed to bill for any claims covered by the QMB program. A mock-up of the new MSN, below, highlights the fact that QMBs owe nothing for such claims.

Clear instruction for program administrators. Consumer advocates say that problems processing QMB coverage have historically occurred because the agency workers charged with administering the program are also confused by the rules and flummoxed about how to enforce them. As another step forward, the Social Security Administration recently revised its program manual to clarify instructions to staff.

Tips for Easing the Application Process

While there is hopeful movement toward better practices in the future, there are a number of steps consumers can take to make sure their rights are honored.

Learn the lingo. If you are required to apply for coverage at an SSA office, tell the worker there that you need “conditional Part A enrollment under HI 00801.140 to apply for your state’s QMB program.” As added protection — or if met with resistance or a blank stare, direct them to the revised program operations manual that spells out the requirements — or print out a copy and bring it along with you.

Document, document, document. Ask the SSA staffer for a printed screenshot of your application. Then bring that along to the Medicaid or Medi-Cal office when progressing to the next step of applying for QMB status.

Get counseling. Once you’ve completed all steps required to file for QMB enrollment, you may still have questions about the coverage, how it works in tandem with other types of Medicare coverage, and which is the best to choose. Free help is available for just this purpose, as part of the State Health Insurance Counseling and Assistance Program (SHIP), though the counseling program goes by a different name in some states.

Correct mistakes. Medicare’s instructions pass the buck for correcting billing mistakes to consumers. The agency advises QMB enrollees who erroneously get a bill for medical care Medicare covers to call their providers or plans about the charges. Tell them that you are a QMB and can’t be charged for Medicare deductibles, coinsurance, and copayments. If this doesn’t resolve the billing problem, call the Medicare office at 1-800-633-4227. A word to the wiser: You may need to fortify with some calming deep breathing before taking this step.