Medical billing
Medicare and Medicaid billing limits, the QMB prohibition and the appeals ladder
NationalUSRead off primary law
United States (federal)
- Rule id
- medical.us-medicare-medicaid
- Version
- 1.0.0
- In force from
- January 1, 1993
- Last read against its sources
- August 5, 2026
- Countries bound
- United States
In plain language
What this regime says.
Medicare and Medicaid cap what a provider may collect from a beneficiary, and the caps are much tighter than commercial ones. A provider accepting assignment may collect only the deductible and coinsurance; one that does not may not exceed the limiting charge of 115 per cent of the non-participating fee schedule amount; a Qualified Medicare Beneficiary may not be billed for Medicare cost sharing at all; and a Medicaid provider takes the programme payment as payment in full.
Who is covered
Medicare beneficiaries, Medicaid recipients, and people enrolled in both. Medicare Advantage enrollees are covered by the plan's own rules and a different appeals process under 42 CFR Part 422 Subpart M.
What you get
A bill limited to the statutory amount, a refund of anything charged above it, no liability for a denied service where no valid advance notice was given, and a five-level appeal that is free and has no minimum amount at its first two levels.
Where claims go wrong
- Paying the difference between the provider's charge and Medicare's approved amount. For a participating provider there is no such difference to pay.
- Not knowing about QMB status, or not mentioning it. The prohibition is absolute and one sentence usually resolves the bill.
- Treating a denial as the end. Redetermination and reconsideration are free, have no minimum amount, and change a large share of decisions.
- Accepting an Advance Beneficiary Notice at face value. Routine, vague or late notices do not shift liability.
- Missing the 120 days for a redetermination. The clock runs from the Medicare Summary Notice, and good cause can extend it — but only if you ask.
Authority
Every citation,
with its pinpoint.
A claim that cites “EU law” gets filed. A claim that cites Article 7(1)(c) gets answered. These are the exact coordinates this entry rests on.
- 42 U.S.C. § 1395u(b)(3)(B)(ii)Social Security Act § 1842, Medicare Part BURL verified 2026-08-05§ 1842(b)(3)(B)(ii) — a provider who accepts assignment agrees to accept the reasonable charge determined by the carrier as the full charge, and may collect from the beneficiary only the deductible and coinsurance
- 42 U.S.C. § 1395w-4(a)(3)Social Security Act § 1848 (Payment for physicians' services)URL verified 2026-08-05§ 1848(a)(3) — the fee schedule amount for services furnished by a non-participating physician who does not accept assignment is 95 per cent of the amount for a participating physician
- 42 U.S.C. § 1395w-4(g)(2)(C); 42 CFR § 414.48Social Security Act § 1848(g); Medicare Program regulations, 42 CFR Part 414URL verified 2026-08-05§ 1848(g)(2)(C) — the limiting charge is 115 per cent of the recognised payment amount for a non-participating physician; 42 CFR § 414.48 — limits on the actual charges of non-participating suppliers, and the obligation to refund a charge that exceeds the limit
- 42 U.S.C. § 1396a(n)(3)Social Security Act § 1902(n)(3), Medicaid State plan requirementsURL verified 2026-08-05§ 1902(n)(3)(A)-(B) — the Medicaid payment for Medicare cost sharing is payment in full, and the provider may not bill a qualified Medicare beneficiary for the balance of any Medicare deductible, coinsurance or copayment
- 42 CFR § 447.15Medicaid Program regulations, 42 CFR Part 447 (Payments for services)URL verified 2026-08-05§ 447.15 — a State plan must provide that the agency limits participation to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan
- 42 CFR §§ 405.942 and 405.950Medicare Program regulations, 42 CFR Part 405 Subpart IURL verified 2026-08-05§ 405.942(a) — a request for redetermination must be filed within 120 calendar days of the date of receipt of the notice of initial determination; § 405.942(b) — extension of the time limit for good cause; § 405.950 — the contractor must issue its redetermination within 60 days
Sources
Where a figure is indexed, converted or published by a regulator rather than fixed in the instrument, the provenance is recorded separately. Anything marked as a modelled estimate is exactly that — a model, not a statutory number.
- Medicare appeals — the five levels, the forms and the current amounts in controversyCenters for Medicare & Medicaid Servicesretrieved 2026-08-05
- Prohibition on billing dually eligible individuals enrolled in the QMB programmeCenters for Medicare & Medicaid Services, Medicare-Medicaid Coordination Officeretrieved 2026-08-05
- Advance Beneficiary Notice of Noncoverage (form CMS-R-131) and the instructions governing when it may and may not be issuedCenters for Medicare & Medicaid Servicesretrieved 2026-08-05
What it imposes
Clocks, defences and the ladder.
A rule module builds these while it evaluates, because a limitation period depends on which forum is open to you. What follows is the structure this regime produces — deliberately with no dates and no figures, because those belong to your facts rather than to the law.
Documents
What this regime can produce.
Every one of these is a document you send yourself, in your own name. Duesday never writes to anybody on your behalf and is never anyone’s agent.
The same claim type elsewhere
EU cross-border healthcare — Directive 2011/24/EU reimbursement, the EHIC and the S2EUSupranational — 27 countriesDirective 2011/24/EU, Arts. 6, 7 and 8Confidence: highFrance — dépassements d'honoraires, secteur 1 and 2, and the OPTAMFRNational — FranceCode de la santé publique, art. R. 4127-53Confidence: mediumGermany — the GOÄ and GOZ private billing schedules and their multiplier limitsDENational — GermanyGebührenordnung für Ärzte (GOÄ), §§ 2, 5 and 12Confidence: mediumIreland — public hospital charges, medical cards and the HSE complaints routeIENational — IrelandHealth Act 1970 (as amended)Confidence: lowItaly — Servizio Sanitario Nazionale, the ticket and the URP routeITNational — ItalyLegge 23 dicembre 1978, n. 833Confidence: lowNetherlands — NZa tariffs, the eigen risico and the SKGZ dispute routeNLNational — NetherlandsWet marktordening gezondheidszorg (Wmg), art. 35Confidence: mediumSpain — Sistema Nacional de Salud coverage and the right to economic informationESNational — SpainLey 41/2002, de autonomía del pacienteConfidence: lowUnited Kingdom — NHS charging, overseas visitor invoices and private healthcareGBNational — United KingdomNational Health Service Act 2006, s. 1(4)Confidence: medium
Other rights in the same countries
Alabama security deposit return — Ala. Code § 35-9A-201US-ALSub-national — United StatesAla. Code § 35-9A-201Confidence: mediumAlabama unclaimed property — Ala. Code §§ 35-12-70 to 35-12-99US-ALSub-national — United StatesAla. Code §§ 35-12-70 to 35-12-99Confidence: mediumAlaska security deposit return — Alaska Stat. § 34.03.070US-AKSub-national — United StatesAlaska Stat. § 34.03.070Confidence: mediumAlaska unclaimed property — Alaska Stat. §§ 34.45.110–34.45.780US-AKSub-national — United StatesAlaska Stat. §§ 34.45.110–34.45.780Confidence: mediumArizona security deposit return — A.R.S. § 33-1321US-AZSub-national — United StatesA.R.S. § 33-1321Confidence: highArizona unclaimed property — Ariz. Rev. Stat. §§ 44-301 to 44-341US-AZSub-national — United StatesAriz. Rev. Stat. §§ 44-301 to 44-341Confidence: mediumArizona surprise out-of-network bill dispute resolution (A.R.S. § 20-3111 et seq.)US-AZSub-national — United StatesA.R.S. § 20-3111 et seq.Confidence: mediumArkansas security deposit return — Ark. Code Ann. § 18-16-306US-ARSub-national — United StatesArk. Code Ann. § 18-16-306Confidence: medium
Does this one reach your facts?
The engine runs every regime that could apply at once and reconciles them, rather than making you guess which page to read.
Not a law firm. Not legal advice. You send it yourself. This page describes a law; it is not advice about your situation and no outcome is promised.