Medicare AdvantageReimbursementHigh impact
Do Not Bill Members With Full Medicaid or 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 or QMB status for any Medicare Advantage cost-sharing amounts. Providers must accept Medicare and Medicaid payments as payment in full and use specific verification systems to check member eligibility status.
Action Required
Immediately: Billing team must verify dual-eligible status for all Medicare Advantage members before billing any cost-sharing amounts. For EmblemHealth members, use ePACES system to check full/partial Medicaid benefits. For ConnectiCare members, verify through Connecticut Department of Social Services (800-842-8440). Stop all balance billing for members with full Medicaid or QMB status and accept Medicare/Medicaid payments as payment in full.