Medicare AdvantageReimbursementHigh impact
Do Not Bill Members With Full Medicaid or Who Are Qualified Medicare Beneficiaries (QMB)
EmblemHealth·CT·Reimbursement
We identified it
Jun 20, 2026
Summary
Healthcare providers are prohibited from balance billing Medicare-Medicaid dual-eligible members who have full Medicaid coverage or are Qualified Medicare Beneficiaries (QMB). Medicare and Medicaid payments must be accepted as payment in full for these members.
Action Required
Immediately: Billing team must identify Medicare-Medicaid dual-eligible members with full coverage or QMB status before billing. Use ePACES system for EmblemHealth members to verify Medicaid benefit level. For ConnectiCare members, verify status through CT Department of Social Services (800-842-8440). Update billing workflows to flag these members and accept Medicare/Medicaid payments as payment in full without balance billing.