11/08/2016

Medicaid Dual Eligible Patients – What to Expect

Many of you continue to have questions regarding whether DPMs can bill Medicaid Qualified Medicare Beneficiaries (QMB) Dual Eligible patients if a service is covered by Medicare but not Medicaid. The answer is no.  No providers may balance bill a patient in this scenario.  The provider will still receive the Medicare payment as long as the service is covered under Medicare, but not a Medicaid payment. 

What the recent New York Medicaid rule change indicates is they will reimburse the “lesser of” the Medicare or Medicaid reimbursement rate.  Approximately 40 states apply the “lesser of” policies.

• The provider receives the Medicare portion (which is 80% of the Medicare rate) if the state Medicaid rate is less.
• The provider receives the Medicaid rate if the Medicare portion (which is 80% of the Medicare rate) is lower, but not to exceed the Medicare rate. 

Scenario 1:  Medicaid rate is less than Medicare portion:

Medicare Rate = $100 (So Medicare portion would be 80% = $80)
Medicaid Rate = $75
Medicaid reimbursement for co-insurance (20%) = $0
Total provider payment is = $80 

The provider receives the Medicare portion of the payment, but since the Medicaid rate is less than Medicare portion, Medicaid will not pay any co-insurance. 

Scenario 2: Medicaid rate is higher than Medicare portion:

Medicare Rate = $100 (So Medicare portion would be 80% = $80)
Medicaid Rate = $83
Medicaid reimbursement for co-insurance (20%) = $3
Total provider payment is = $83

The provider receives Medicare portion ($80) plus the Medicaid co-insurance portion ($3).