Wiki Contracted with Medicare/other insurances but not Medicaid


Easton, PA
Best answers
If a practice is contracted with Medicare and other commercial insurances, but not medicaid.. Does the patient legally have to pay their primary insurance co-pay?

For example, the patient's primary insurance is United, but their secondary is some type of medicaid plan. If United decides there is a $30 co-pay, but the practice is not contracted with medicaid... does the patient still pay that $30 co-pay? Does this vary by state?
Be very, very careful here. Alot of practices get this wrong. If someone has any kind of Medicare plan (including Medicare replacement plans, except certain HMOs that are allowed to designate a low copay to the patient such as $10), you cannot charge them a copay or deductible.

If a patient is a "Qualified Medicare Beneficiary" (their eligibility on medicare webpage will say QMB), you CANNOT charge them any copay whatsoever. It does not matter if Medicare pays you nothing (puts everything to deductible), and you cannot bill Medicaid - you get zero for your services:

What are the Billing Requirements Affecting People in the QMB Program? (Click me)
Medicare providers and suppliers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Under some circumstances, federal law lets states limit how much they pay providers for Medicare cost-sharing. Even when that's the case, people in the QMB program have no legal obligation to pay Medicare providers for Medicare Part A or Part B cost-sharing.

Despite these billing rules, our July 2015 study found that those in the QMB program are still being wrongly billed and that confusion about billing rules continues. We're sharing this information to help you understand the QMB program and its billing rules.


Medlearn article here.


If someone has a non-Medicare plan plus Medicaid, it is up to each individual state on whether or not the patient has to pay, and you can refuse to see the patient. In my state, you can have the Medicaid patient sign a waiver saying they will be a cash pay patient, if they want to see a non-Medicaid provider.