Current through Register Vol. 35, No. 18, September 24, 2024
MAD covers medically necessary health services furnished to a
MAP eligible recipient who meets specific income, resource and eligibility
standards. Medicare is a federal program which offers health insurance coverage
to MAP eligible recipient 65 years of age and older, to those who have received
disability benefits for 24 consecutive months, to those who have end stage
renal disease, and to other MAP eligible recipients as specified by other
provisions of the Social Security Act.
A. New Mexico has entered into an agreement
with the social security administration to pay a medicaid MAP eligible
recipient's premium for medicare part B, and under some circumstances, medicare
part A premiums.
B. After medicare
has made payment for services, MAD pays for the medicare co-insurance,
deductible and copayment amounts for a MAP eligible recipient subject to the
following reimbursement limitations.
(1)
Medicaid payment for the co-insurance, deductible, copayment or other patient
responsibility is limited such that the payment from medicare, plus the amount
allowed by MAD for the co-insurance, copayment and deductible, shall not exceed
the MAD allowed amount for the service. When the medicare payment exceeds the
amount that medicaid would have allowed for the service, no payment is made for
the co-insurance, copayment, deductible or other patient responsibility. The
claim is considered paid in full. The provider may not collect any remaining
portion of the medicare co-insurance, copayment or deductible from the MAP
eligible recipient or his or her authorized representative. For services for
which medicare part B applies a 50 percent co-insurance rate, medicare
co-insurance, copayment and deductible amounts are paid at an amount that
allows the provider to receive more than MAD allowed amount, not to exceed a
percentage determined by HSD.
(2)
MAD will pay toward the medicare co-insurance and deductible to the extent that
the amount paid by medicare and the allowed medicare co-insurance, deductible
and copayment together do not exceed the MAD allowable amount. MAD will pay the
full medicare co-insurance and deductible when MAD does not have a specific
amount allowed for the service. When MAD does not use an equivalent payment
methodology for a service, the full coinsurance, deductible and copayment
amounts will be paid. This occurs when providers are paid at encounter rates,
percent of billed charges followed by cost settlements, or when providers are
entitled to a full reimbursement rate such as for federally qualified health
centers and hospital outpatient prospective payment system
reimbursement.
