Qualified Medicare Beneficiary (QMB) Status and Its Role in APCM

Definition of Qualified Medicare Beneficiary 

The QMB program is one of the Medicare Savings Programs (MSPs) designed to help low-income individuals afford their healthcare costs. Specifically, the QMB program covers Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. This means that if a patient is enrolled in the QMB program, they shouldn't be billed for any Medicare-covered services. 

Who Qualifies as a Qualified Medicare Beneficiary? 

Eligibility for the QMB program is determined by income and resource limits set by the federal government. Generally speaking, a person can qualify as a Qualified Medicare Beneficiary if they: 

1. are enrolled in Medicare Part A (hospital insurance) and/or Part B (medical insurance); and
2. meet specific income and asset requirements.

In 2025, the income limits for QMB eligibility are set at 100% of the federal poverty level (FPL) or less. For individuals, this typically means a monthly income of $1,325 or less, and for married couples, a combined monthly income of $1,783 or less. The asset limits are $9,660 for individuals and $14,470 for couples. These assets include savings, investments, and real estate (other than a primary home). 

Once enrolled, QMB beneficiaries are not responsible for paying Medic7are costs like copayments or coinsurance. This protection is crucial for ensuring that low-income seniors and individuals with disabilities can receive necessary medical care without financial strain. 

There are two types of QMBs: "QMB only without other Medicaid," which refers to a Medicare coverage program for low-income individuals who are not eligible for full Medicaid, and QMB Plus (QMB+), which is a program that provides benefits to people eligible for both the QMB program and full Medicaid coverage. A CMS Medicare Learning Network fact sheet breaks down the benefits and qualifications of these two types of QMBs as follows: 

Qualified Medicare Beneficiary (QMB) Only Without Other Medicaid 

Benefits 

• Medicaid covers Part A (if any) and Part B premiums 
• Medicaid covers Medicare deductibles, coinsurance, and copayments for Medicare-covered items and services. Even if Medicaid doesn't fully cover these charges, the QMB isn't liable for them.  

Qualifications 

• Income can be up to 100% of the FPL 
• Resources can be up to 3 times the Supplemental Security Income resource limit, increased annually by the consumer price index 
• Enrolled in: 
  • Part A 
  • For those without Part A, depending on the state, either: 
    • Part B only 
    • Part B and conditional Part A 

Qualified Medicare Beneficiary Plus (QMB+) 

Benefits 

• Medicaid covers Part A (if any) and Part B premiums 
• Medicaid covers Medicare deductibles, coinsurance, and copayments for Medicare-covered items and services. Even if Medicaid doesn't fully cover these charges, the QMB+ isn't liable for them. 
• Get full-benefit Medicaid coverage plus Medicare premiums and cost-sharing coverage 
  

Qualifications 

• Meet QMB-related eligibility requirements (as listed in the "QMB only without other Medicaid" section) 
• Enrolled in full Medicaid coverage (beyond Medicare premiums and cost-sharing coverage) 

How Does Advanced Primary Care Management (APCM) Apply to Qualified Medicare Beneficiaries? 

Advanced Primary Care Management is focused on improving patient outcomes, especially for those with chronic illnesses or complex care needs. It emphasizes proactive, team-based care and can include valuable, additional services like remote patient monitoring (RPM). 

As noted earlier, when CMS created the new APCM program, it established billing codes specifically for the new service, with each code reflecting the level of patient complexity and intensity of care. Those codes and their 2025 reimbursement are as follows: 

• G0556: For patients with one chronic condition or fewer, reimbursed at approximately $15 per month. 
• G0557: For patients with two or more chronic conditions, reimbursed at around $50 per month. 
• G0558: For high-complexity patients with QMB status and two or more chronic conditions, reimbursed at approximately $110 per month. 

The final code, G0558, is specific to QMB patients, and it's the code that reimburses the most of the three new APCM codes. Providers launching an APCM program would be wise to enroll QMB patients — not only because of the financial value, but APCM is particularly well-suited for QMB patients for several reasons: 

• QMB patients often have multiple chronic conditions that require ongoing care coordination. APCM helps ensure they receive regular check-ins, care planning, and preventive services. 
• Since the QMB program covers all Medicare expenses, including out-of-pocket costs, APCM services are more accessible to these patients. Providers can deliver APCM without worrying about whether the patient can afford the associated costs. 
• APCM's preventive approach helps QMB patients avoid costly hospitalizations and complications, improving their quality of life and reducing overall healthcare spending. 

What is Required to Provide and Bill for APCM Services to Qualified Medicare Beneficiaries? 

When offering APCM services to QMB patients, providers need to meet a few key requirements to ensure proper billing and compliance. 

1. Eligibility verification. Before delivering APCM services, confirm the patient's QMB status using tools like the Medicare Administrative Contractor (MAC) online provider portal; billing agencies, clearinghouses, or software vendors; or the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS). This step helps ensure accurate billing and prevents incorrect patient charges. Another way to verify eligibility: Request a patient's QMB card. Each state will provide its QMBs with a card indicating their QMB status. 
2. Service documentation. APCM services must be thoroughly documented. This includes time spent, care plan details, patient goals, and communication logs.
3. Compliance with billing codes. Providers must use the appropriate Medicare billing codes for APCM services. For QMBs receiving APCM services, that means HCPCS G0558. If providers integrate remote patient monitoring (RPM) with APCM, for example, they will need to properly code and bill for RPM as well.
4. No balance billing. Under federal law, providers cannot bill QMB patients for Medicare-covered services, even if Medicare doesn't fully reimburse the provider. It's essential to train staff to avoid billing QMB patients in error.

While not a requirement, using a remote care platform like Prevounce can streamline APCM service delivery, documentation, and billing. These tools help providers stay compliant and ensure accurate, complete reimbursement. 

Benefits of Providing APCM Services to Qualified Medicare Beneficiaries 

Let's take a closer look at the benefits of delivering APCM to QMB patients. 

For patients 

• Improved outcomes — APCM's focus on regular monitoring, preventive care, and coordinated services helps QMB patients better manage chronic conditions like diabetes, heart disease, and chronic obstructive pulmonary disease (COPD). 
• Financial relief — Since QMB covers Medicare costs, patients receive high-quality care without worrying about unaffordable or difficult medical bills. 
• Enhanced engagement — APCM services encourage patients to take an active role in their healthcare, often leading to better adherence and outcomes. 
• Reduced hospitalizations — Proactive management helps identify issues before they escalate, reducing the need for hospital visits and emergency care. 

For Providers 

• Consistent revenue — APCM services are covered by Medicare and billed monthly, providing a steady income stream — at a time when reimbursement is under pressure — while helping providers meet quality care metrics. 
• Patient satisfaction and retention — Offering comprehensive, accessible care builds trust and loyalty, encouraging patients to stay engaged with and committed to their primary care providers. 
• Efficiency and workflow optimization — Since APCM integrates well with technology like RPM and care management software, providers gain the ability to monitor patients remotely, document efficiently, and streamline workflows, all while maintaining compliance. 

Advanced Primary Care Management: A Must-Have for Qualified Medicare Beneficiaries 

With its APCM coding and reimbursement decisions, CMS is clearly trying to motivate primary care providers and organizations with Advanced Primary Care Management programs to enroll QMBs. APCM can help keep QMBs healthier, thus reducing the need for costly services like emergency room visits and hospital admissions. Meanwhile, by understanding QMB eligibility, following billing requirements, and leveraging technology to streamline workflows, primary care providers broaden their approach to patient care while benefitting from a stable, recurring revenue stream. 

Organizations that are approved direct trading partners with Medicare have real-time electronic access to check QMB status. APCM platforms with this access, like Prevounce, can automatically notify and adjust your billing to make sure you are getting fully reimbursed while remaining compliant. 

APCM is a win-win-win for QMB patients, providers, and the healthcare system as a whole. If you are interested in learning more about the new Advanced Primary Care Management, watch the on-demand webinar, "Crash Course on Advanced Primary Care Management."