Seniors and People with Disabilities
Cathy Cooper
Authorized Signature
Number: SPD-PT-07-012
Issue Date: 6/12/2007
Topic: Medical Benefits
Transmitting (check the box that best applies):
New Policy
Policy Change
Policy Clarification
Administrative Rule
Manual Update
Applies to (check all that apply):
All DHS employees
Area Agencies on Aging
Children, Adults and Families
County DD Program Managers
Policy/Rule Title:
Policy/Rule Number(s):
Effective Date:
Web Address:
Executive Letter
County Mental Health Directors
Health Services
Seniors and People with Disabilities
Other (please specify):
QMB Benefits with Medicare Advantage plans as primary
Release No:
OAR 461-135-0730
Discussion/Interpretation: With the passage of the Medicare Modernization Act, a
large number of organizations began to offer all Medicare benefits in a single,
coordinated plan, called Medicare Advantage (MA) Plans. Clients who have Medicare
A and B, who are not receiving continuing dialysis treatments, are eligible to enroll in a
private Medicare Advantage plan if they live in the plan’s service area.
While these coordinated-care plans can be beneficial to clients, it is important to
understand some of the payment parameters and requirements, before clients enroll in
the plans. There has been some confusion regarding how clients are able to access
their QMB-only benefits through the Department when receiving their Medicare A, B,
and D benefits from an MA plan. This transmittal clarifies the Department’s payment
policy regarding QMB benefits received when an MA plan is the primary payer.
Implementation/Transition Instructions: The Department does not pay the MA plan
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monthly premium (if any), but will continue to pay for Part B and, if applicable, Part A
premiums to the Centers for Medicare and Medicaid Services (CMS).
The Department pays for co-insurance and deductibles for Medicare Part A and B
covered items and services where an MA plan paid in lieu of Original Medicare, if the
services are received from a Department enrolled provider. Additionally, the
Department pays according to the Department’s fee schedule and based on Original
Medicare payment parameters, as per OAR 461-135-0730(1):
(b) Clients who qualify for QMB-BAS are not eligible to receive the full range of the
Department's medical services. QMB-BAS benefits are limited to payments toward
Medicare cost-sharing expenses. These expenses are:
(A) Medicare Part A and Part B premiums; and
(B) Medicare Part A and Part B deductibles and coinsurance up to the Department's fee
The problem is in processing payments, as there is not a “cross-over claims” process
like with Original Medicare. (Cross-over claims require only one action from the
provider, who receives both the primary and secondary payments from that single
action.) To ensure that QMB payments are processed correctly, as secondary to MA
plans, the Department has a unique form to be used by providers. The provider first
bills the MA plan, and must wait until the plan pays. Then the provider submits a
paper form "OMAP-0505" to the Department. The MA plan payment has to be
marked as a Medicare payment on the form and submitted to the Department.
Questions on this process should be referred to DMAP Provider Services Unit (800336-6016).
Training/Communication Plan: The Department is releasing a provider notice to
communicate the correct billing procedures to follow with MA plans and other plans
that pay in place of Medicare. The Department has developed an informational flyer to
help QMB clients know what questions to ask before they sign up for an MA plan.
Local/Branch Action Required: When choice counseling QMB eligible clients,
please provide the educational QMB-MA flyer to all QMB only clients informing them
that they may choose an MA plan, if eligible. Please inform clients that he or she will
be responsible for any monthly premiums due to the plan outside of the Medicare Part
D subsidy.
Central Office Action Required:
Field/Stakeholder review:
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If yes, reviewed by: SPD Operations Committee
Filing Instructions:
If you have any questions about this policy, contact:
Contact(s): Christina Jaramillo
Phone: 503-947-5281
Fax: 503-373-7274
E-mail: [email protected]
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Important Information for
People in the Qualified
Medicare Beneficiary (QMB) Program
Your Oregon Health Plan-QMB (Medicaid) benefits pay for your monthly Medicare
premiums, deductibles, and co-insurance amounts. If you receive your benefits from
a doctor or other medical provider enrolled with Medicaid and who accepts Original
Medicare, you should not have to pay anything for your Medicare covered medical
services. You do not need to join a separate insurance plan to receive your Medicare
covered medical benefits.
You must join a private plan for Medicare drug coverage. You can join a Prescription
Drug Plan (PDP), that offers only prescription drugs, or you may join a private
Medicare Advantage plan that provides all Medicare covered services (hospitals,
doctors, and prescriptions) in one coordinated plan. You will have small copayments
for your prescription drugs.
These coordinated-care plans must provide the same benefits as Original Medicare.
However, there are some things that you should think about before you join a
Medicare Advantage plan, or if you have a Medicare Advantage plan now.
Have you asked these questions?
Do your doctors and other providers bill your Medicare plan and Medicaid?
You may have to pay some of the costs if your providers are not
enrolled with the Oregon Health Plan (Medicaid) and do not
accept your Medicare Advantage plan's payments.
Do you have a monthly premium for the Medicare Advantage plan?
Medicaid does not pay monthly premiums for Medicare Advantage
plans. You may get lower premiums for the drug coverage in the
plan, due to your QMB benefit. However, you will be responsible for
the full premium for the medical part of the plan.
What does the plan cover that you do not already have coverage for?
Your QMB medical benefits pay for your monthly Medicare premiums,
deductibles, and co-insurance amounts, as long as your provider takes
Medicare and OHP. You have no cost-sharing for Medicare-covered
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medical services. You will have small copayments for your Medicarecovered prescriptions received through your Prescription Drug Plan.
Does the Medicare Advantage plan serve where you live?
Medicare Advantage plans provide services in specific areas of the
state. If you enroll in a Medicare Advantage plan, you must live in
and receive most of your care in that service area.
The answers to the above questions are important and may affect your OHP-QMB
coverage. If you have questions on your benefits call your case worker. If you have
questions about what your Medicare Advantage plan covers, please call your plan or
Medicare at 1-800-633-4227.
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