Attention Qualified Medicare Beneficiaries (QMBs) – Increased Access to Care Beginning January 1, 2013

As many QMBs and Medicare counselors know, it can be difficult for QMBs to get access to physician care as in most states the Medicaid state agency (which runs the QMB program) will pay a physician (or other practitioner) only the difference between what Medicare pays for a service and what Medicaid would pay for the same service. In many cases, this is nothing, and, coupled with the fact that a physician or practitioner cannot balance bill a QMB, they often refuse to see one of these beneficiaries, as they believe their reimbursement is insufficient.

However, beginning January 1, 2013, a provision of the Affordable Care Act requires states to pay primary care physicians and practitioners at full Medicare rates. And among other things, this means that for QMBs, state agencies must pay the full difference between what Medicare allows and the (usual) 80% that it actually pays. So it well may be that your doctor or practitioner will now see you, as they will get reimbursed for their care for you at what they would for any other Medicare beneficiary (presuming they take assignment, of course). There is a catch, and it is that this provision in the law speaks only to those practicing family medicine, general internal medicine, and pediatric medicine, so you are not covered by this if you see a specialist. But it will quite possibly apply to someone you do go to seek care from, and you can bring this provision up when you try to make an appointment with a primary care physician or practitioner.