Iowa Admin. Code r. 441-77.53

Current through Register Vol. 47, No. 11, December 11, 2024

Rule 441-77.53 - Qualified Medicare beneficiary (QMB) providers

Any Medicare provider not enrolled as an Iowa Medicaid provider for the general Medicaid population may enroll to be a QMB provider.

(1)Reimbursement. A QMB provider may only bill the department for the QMB-eligible member's Medicare cost-sharing obligations. Reimbursement is limited to coinsurance, copayments, and deductibles for Medicare-covered services.

(2)Definitions.

"Coinsurance" means a percentage of costs of a covered health care service that has to be paid.

"Copayment" means a fixed amount a member pays for a covered health care service.

"Deductible" means the amount paid for covered health care services before the insurance plan will effect payment.

"Medicare cost sharing" means the Medicare member's responsibility for a Medicare-covered service. "Medicare cost sharing" includes coinsurance, copayments, and deductibles.

"Qualified Medicare beneficiary" or "QMB" means an individual who has been determined eligible for the QMB program pursuant to 441-subrule 75.1(29). Under the QMB program, Medicaid pays the individual's Medicare Part A and B premiums; coinsurance; copayment; and deductible (except for Part D).

This rule is intended to implement Iowa Code section 249A.4.

Iowa Admin. Code r. 441-77.53

Adopted by IAB December 6, 2017/Volume XL, Number 12, effective 1/10/2018