Can you bill a QMB patient for a Medicare copay?

No. Qualified Medicare Beneficiaries are dual-eligible patients whose Medicare cost sharing is the responsibility of their state Medicaid program, and federal rules prohibit providers from billing them for Medicare deductibles, coinsurance or copays. This holds even where the state pays the provider little or nothing. QMB status is identifiable at verification, which is the point at which it should be recorded.

Is Medicare Advantage verified the same way as Original Medicare?

No. A Medicare Advantage plan is administered by a commercial carrier and follows that carrier's rules, including its behavioral health carve-out, its prior authorization requirements and its own network. A UnitedHealthcare Advantage plan routes behavioral health to Optum; a Florida Blue Advantage plan routes to Lucet. Verifying an Advantage plan through the Medicare contractor returns an answer that does not govern the claim.

Why does Railroad Medicare need a separate registration?

Railroad Medicare is administered nationally by Palmetto GBA rather than by the regional Medicare Administrative Contractors, so eServices access with Palmetto is required in addition to whatever access a practice holds with its own MAC. Volume is typically very low, which is why the registration is usually missing at the moment it is first needed.

Payer routing · Medicare

Medicare has no carve-out.
It has other traps.

Q: Does Original Medicare carve out behavioral health?

No. Original Medicare Part B covers outpatient behavioral health directly, with no separate behavioral administrator. Eligibility is verified through the Medicare Administrative Contractor for your jurisdiction, using a portal tied to your PTAN and NPI. In Florida that is First Coast Service Options and the SPOT portal.

Original Medicare is the one payer family where the behavioral benefit sits exactly where the card says it does. What replaces the carve-out problem is a state-specific portal, a separate registration for Railroad Medicare, and a billing rule that a lot of practices break by accident.

See the routing table → Provider lines

The short answer

Original Medicare Part B has no behavioral health carve-out. Eligibility is verified through the Medicare Administrative Contractor for your state, using a portal tied to your PTAN and NPI. In Florida that contractor is First Coast Service Options and the portal is SPOT.

Three things sit underneath that. Railroad Medicare needs its own registration with Palmetto GBA, separate from your MAC. Medicare Advantage is not Medicare: it routes like the parent carrier’s commercial line, carve-out and all. And if the patient is a Qualified Medicare Beneficiary, federal rules prohibit billing them for Medicare cost sharing at all.

The routing table

Four things that all say Medicare.

The word on the card is the same in every row below, and the verification path is different in every one. Establishing which of the four you are looking at is the entire job.

Plan family	Step 1 · eligibility	Step 2 · behavioral	What to watch
Original Medicare
Medicare Part B	Your state’s MAC portal. In Florida, SPOT (First Coast)	None. Original Medicare does not carve out	Access is tied to your PTAN and NPI, so it has to be set up per practice, not per person.
Railroad Medicare	Palmetto GBA eServices	None	A separate registration even if you already hold MAC access. Low volume, and a guaranteed delay if you set it up on the day you need it.
Medicare as secondary
Medicare secondary to a commercial plan	Both: the primary payer and the MAC	Follows the primary’s rules	Verify the primary first, then confirm Medicare’s secondary liability. Skipping the second step is how a balance ends up with the patient.
Medicare Advantage
UHC, Aetna, Florida Blue and other MA plans	The parent carrier’s portal	The parent carrier’s carve-out	Advantage plans carve out exactly as their commercial siblings do, and add their own authorization rules.
BayCarePlus Medicare Advantage	provider.baycareplus.org	Not confirmed	Confirm both the behavioral administrator and whether the specific clinician is contracted; participation is not practice-wide.
Supplements
Medicare Supplement, including AARP	The MAC, then the supplement	Follows Original Medicare	A supplement is not an Advantage plan and does not carve out. Verify Original Medicare first.

Portal URLs: SPOT (First Coast, Florida) thespot.fcso.com · Palmetto GBA eServices palmettogba.com · BayCarePlus provider.baycareplus.org · Outside Florida, use the MAC portal for your jurisdiction.

Where Medicare claims go wrong

The billing rules are the risk, not the routing.

Balance billing a QMB patient

A Qualified Medicare Beneficiary is a dual-eligible whose Medicare cost sharing is covered by their state Medicaid program. Federal rules prohibit billing these patients for Medicare deductibles, coinsurance or copays, whether or not the state actually pays the practice. QMB status is visible at verification and invisible at check-in, which is exactly why it belongs in the note before the visit rather than in a collections conversation afterwards.

Treating a Medicare Advantage plan as Medicare

An Advantage plan is a commercial product with a Medicare label. It carves out behavioral health the way its commercial sibling does, imposes its own prior authorization, and maintains its own network. Verifying it through the MAC returns a clean, useless answer.

Setting up Railroad Medicare on the day you need it

Railroad Medicare runs through Palmetto GBA and requires its own registration regardless of what access you already hold. Volume is usually a handful of patients a year, which is precisely why nobody registers until a patient is on the schedule and it is too late to be useful.

Provider lines

The numbers that actually reach a person.

Provider lines only. Contractor lines are jurisdictional: the numbers below are Florida and Railroad Medicare, and practices in other states should use the MAC for their own jurisdiction.

First Coast Service Options · Florida

866-454-9007

Mon–Fri, 8am–4pm ET. Automated line 877-847-4992. This is the Part B contractor for Florida; other states have their own.

Palmetto GBA · Railroad Medicare

888-355-9165

Mon–Fri, 8:30am–4:30pm. Separate registration from your MAC, even if you already have eServices access.

BayCarePlus

866-509-5396

8am–8pm, seven days. A shared member and provider line, so identify yourself as a provider immediately.

Before you dial

What to have in front of you.

The card, both sides

Front and back, as an image. On self-funded and third-party administered plans, the back of the card is often the only reliable routing information that exists.

Your NPI and tax ID, and the rendering clinician’s NPI

Behavioral network status is answered per clinician, not per practice. Asking about the group gets you an answer that may not apply to the person actually seeing the patient.

The CPT code and the date of service

Cost share, limits and authorization rules differ by service. Verify for the date of service, not for today, and for telehealth confirm both coverage and the expected place-of-service code.

A transaction or reference number, if the portal issued one

Some portals dead-end a call without it. And when a payer issues none at all, record that explicitly rather than leaving the field empty, so a later reader can tell the difference between “none exists” and “nobody checked.”

Verified 13 August 2026. Payer phone trees, portal names and carve-out arrangements change without notice, and self-funded groups can change administrators at renewal. Treat this as a starting point rather than an authority: confirm against the member’s card and the portal on the date of service. Product and company names are the property of their respective owners and appear here for identification only; no affiliation or endorsement is implied.

Elsewhere in the library

Other payer families.

UnitedHealthcare

UnitedHealthcare & Optum

Provider Express for almost everything, with four exceptions.

Cigna & Evernorth

One carve-out, no exceptions, and a batch route most practices miss.

Aetna

No carve-out at all, which creates a different problem.

See the whole payer routing library →

Or hand the
routing to us.

We keep this map current across every payer family and run it against your whole upcoming schedule, before the patient walks in, inside the EHR you already use.

Book a call →Run the denial math

Medicare has no carve-out.It has other traps.