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Medicare AdvantageReimbursementHigh impact

Do Not Bill Members with Full Medicaid or QMB

EmblemHealth·CT·Reimbursement
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply
—

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 or additional costs. Medicare and Medicaid payments must be accepted as payment in full for these members.

Action Required

Action needed
Immediately: Billing team must update patient eligibility verification procedures to check dual eligible status before billing. Use ePaces for EmblemHealth members and CT Department of Social Services (800-842-8440) for ConnectiCare members to verify full vs partial Medicaid benefits. Update billing system to flag dual eligible patients with full Medicaid/QMB status to prevent balance billing. Train staff that Medicare and Medicaid payments constitute payment in full for these members.

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