Can SLMB Patients Be Billed? What Providers Should Know

The Specified Low-Income Medicare Beneficiary (SLMB) program is a component of the broader Medicare Savings Programs (MSPs), designed to assist low-income Medicare beneficiaries with certain healthcare costs. These programs, administered by state Medicaid agencies, aim to reduce the financial burden on individuals who meet specific income and resource guidelines.

What SLMB Covers

The SLMB program specifically helps beneficiaries by covering their Medicare Part B premiums. The SLMB program pays the standard Part B premium on behalf of the beneficiary. This financial assistance can result in significant annual savings for eligible individuals.

To qualify for SLMB, individuals must be enrolled in Medicare Part A and eligible for Medicare Part B. While SLMB covers Part B premiums, it does not cover other cost-sharing amounts such as Medicare deductibles, coinsurance, or copayments for services, unlike the Qualified Medicare Beneficiary (QMB) program. Eligibility for SLMB is tied to federal poverty levels, with income limits typically ranging from 100% to 120% of the Federal Poverty Level (FPL), though specific thresholds and resource limits vary by state and are updated annually.

Billing Restrictions for SLMB Patients

Providers are prohibited from balance billing SLMB patients for services covered by Medicare. Balance billing occurs when a provider attempts to charge a patient the difference between the Medicare-approved amount and the provider’s charge. For SLMB patients, this prohibition extends to the Medicare Part B premiums, as these are paid by the state Medicaid agency.

Healthcare providers who accept Medicare assignment agree to accept the Medicare-approved amount as payment in full. If a patient is also eligible for Medicaid, the state Medicaid agency typically acts as the payer of last resort for any remaining cost-sharing for services covered by Medicare. Federal law prohibits providers from billing SLMB or other Medicare Savings Program beneficiaries for Medicare cost-sharing, including premiums, deductibles, coinsurance, and copayments.

Confirming SLMB Eligibility

Healthcare providers can verify a patient’s SLMB status through various methods to ensure proper billing and compliance. One common approach involves checking the patient’s insurance cards, which may indicate enrollment in Medicaid or a Medicare Savings Program. Many states utilize electronic Medicaid eligibility verification systems (MEVS) that allow providers to confirm a patient’s current eligibility status in real-time.

These systems provide date-specific eligibility information and can help prevent claim denials. Providers can access these systems online through secure portals or by using specific vendor services. Providers should routinely check eligibility, not just upon initial admission, but periodically throughout the course of treatment, as eligibility can change.

How Providers Are Paid for SLMB Services

For services rendered to SLMB patients, the payment mechanism involves a coordinated effort between Medicare and the state Medicaid agency. Medicare processes and pays its portion of the claim first, based on the Medicare-approved amount for the covered service.

Providers are required to accept the combined payment from Medicare and the state Medicaid agency as payment in full. They cannot seek additional payment from the patient for any Medicare-covered costs for which the patient is relieved of liability due to their SLMB status. Providers should submit claims for services not covered by Medicare directly to the state Medicaid program as regular Medicaid claims.