Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 29 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - MEDICARE COST SHARING PROGRAM
Article 3 - BENEFITS AND SERVICES
Section R9-29-302 - QMB Dual Member

Universal Citation: AZ Admin Code R 9-29-302

Current through Register Vol. 30, No. 38, September 20, 2024

A. Covered services. A person determined to be a QMB Dual eligible member shall receive medical services provided under 9 A.A.C. 22, Article 2, or services provided under 9 A.A.C. 28, Article 2, in addition to the Medicare-related payments under R9-29-301(A).

B. Premiums. The Administration pays Medicare part A and B premiums for a QMB Dual member enrolled with a contractor in a plan or AHCCCS Fee-For-Service.

C. The Administration's payment responsibilities.

1. The Administration shall pay the following costs for members not enrolled with contractors. When services are received from an AHCCCS registered provider and the service is covered:
a. By Medicare only, the Administration shall pay the Medicare coinsurance and deductible.

b. By Medicaid only, the Administration shall pay the lesser of billed charges or the Capped Fee-For-Service Schedule rate for the services covered under 9 A.A.C. 22, Article 2 and 9 A.A.C. 28, Article 2.

c. By both Medicare and Medicaid, the Administration shall pay Medicare coinsurance and deductible.

2. When services are received from a non-registered provider and the service is covered, the Administration shall not pay the Medicare coinsurance and deductible.

D. The contractor's payment responsibilities. Unless the subcontract with the provider sets forth different terms, when the enrolled member receives services from an AHCCCS registered provider in or out of network and the service is covered:

1. By Medicare only, the contractor shall pay the Medicare coinsurance and deductible.

2. By Medicaid only, the contractor shall pay the provider in accordance with the contract.

3. By both Medicare and Medicaid, the contractor shall pay the lesser of:
a. The Medicare copay, coinsurance or deductible, or

b. The difference between the Health plan contracted rate and the Medicare paid amount.

E. Member responsibilities. A QMB Dual eligible member who receives services under 9 A.A.C. 22, Article 2 or 9 A.A.C. 28, Article 2 from a registered provider is not liable for any Medicare copay, coinsurance or deductible associated with those services and is not liable for any balance of billed charges.

F. Coordination of prescription drug benefit with Medicare Part D. Notwithstanding subsections (A) through (D), services do not include pharmaceutical services to the extent limited under 42 U.S.C. 1396u-5(d). A contractor is not liable for any Medicare copay, coinsurance or deductible associated with pharmaceutical services subject to the limitation under 42 U.S.C. 1396u-5(d).

Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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