Current through Register Vol. 42, No. 11, August 30, 2024
Medicaid pays the monthly premiums for Medicare insurance for
an eligible Medicare/Medicaid and/or QMB recipient to the Social Security
Administration. Medicaid also pays the applicable Medicare Part A and Part B
deductibles and/or coinsurance for an eligible Medicare/Medicaid and/or QMB
recipient, as specified below.
(1)
Definitions
(a) "QMB" recipient is a Part A
Medicare beneficiary whose verified income and resources do not exceed certain
levels.
(b) "Deductible" is the
dollar amount a Medicare eligible must pay for his/her own health care
services.
(c) "Coinsurance" is the
percentage of each bill a Medicare eligible must pay under certain conditions,
in addition to the deductible amount.
(2) Part A
(a) The Part A deductible less any applicable
copay or coinsurance days are covered Medicaid services. For QMB recipients,
the inpatient hospital deductible less any applicable copay, coinsurance days
and lifetime reserve days are covered services for any inpatient
admission.
(b) Medicaid may pay the
Part A coinsurance for the 21st day through the 100th day for Medicare/Medicaid
and/or QMB eligible recipients who qualify under Medicare rules for skilled
level of care. An amount equal to that applicable to Medicare Part A
coinsurance, but not greater than the facility's Medicaid rate will be paid for
the 21st through the 100th day. No payment will be made by Medicaid (Title XIX)
for skilled nursing care in a dual certified nursing facility for the first 20
days of care for recipients qualified under Medicare rules.
(c) Medicare pays in full for
Medicare-approved home health services, therefore, Medicaid has no liability
for these services.
(d) Medicare
pays in full for Medicare-approved hospice services, therefore, Medicaid has no
liability for these services.
(e)
Medicaid covers Medicare coinsurance days for swing bed admissions for QMB
recipients. An amount equal to that applicable to Medicare Part A coinsurance,
but not greater than the Medicaid swing bed rate, will be paid.
(f) Medicaid will pay Part A claims in
accordance with Medicaid reimbursement methodology for Medicare recipients who
have exhausted their life-time Medicare benefits. Those claims must be filed
directly to Medicaid in accordance with instructions in Chapter 19 of the
Alabama Medicaid Provider Manual.
(3) Part B
(a) Except as provided in this subsection,
Medicaid pays the Medicare Part B deductible and coinsurance to the extent of
the lesser of the level of reimbursement under Medicare rules and allowances or
total reimbursement allowed by Medicaid less Medicare payment.
(b) Medicare related claims for QMB
recipients shall be reimbursed in accordance with the coverage determination
made by Medicare. Medicare related claims for recipients not categorized as QMB
recipients shall be paid only if the services are covered under the Medicaid
program.
(c) Medicare claims for
rented durable medical equipment shall be considered for payment if the
equipment is covered as a purchase item under the Medicaid Program. Rental
payments and purchases on non-covered Medicaid items for QMB recipients shall
also be considered for payment.
(4) When a Medicaid recipient has third party
health insurance of any kind, including Medicare, Medicaid is the payer of last
resort. Thus, provider claims for Medicare/Medicaid eligibles and QMB eligibles
must be sent first to the Medicare contracted intermediary. Claims paid by the
Medicare contracted intermediary will be electronically forwarded to Medicaid's
fiscal agent for payment of the Medicare cost-sharing charges. Claims denied by
the Medicare intermediary are not forwarded to the Medicaid fiscal agent.
Chapter 20 of this Code contains additional health insurance information.
(a) Providers will complete the appropriate
Medicare claim forms ensuring that the recipient's 13-digit Medicaid ID number
is on the form. The completed claim shall be forwarded to an Alabama Medicare
carrier for payment.
(b) If the
provider's claim for service is rejected by the Medicare carrier as "Medicare
non-covered service" but is a covered Medicaid service, a Medicaid claim form,
completed in accordance with instructions in the Alabama Medicaid Provider
Manual, with a copy of the Medicare rejection statement, should be sent to the
Medicaid fiscal agent for payment. QMB-Only recipients are not entitled to
Medicaid coverage for Medicare non-covered services.
(c) Providers in other states who render
Medicare services to Alabama Medicare/Medicaid eligibles and QMB eligibles
should file claims first with the Medicare carrier in the state where the
service was performed.
Author: Solomon Williams, Associate Director,
Institutional Services
Statutory Authority: State Plan, Attachments
3.2-A and 3.5-A;
42 C.F.R.
§431.625; Social Security Act, Title
XIX; Medicare Catastrophic Coverage Act of 1988 ( Public Law 100-360).
