Can we billed Medicaid patient for Medicare coins ?

Can you clarify if Medicaid only covers Medicare part B premium? Is the patient responsible for the 20% coinsurance?

If you are referring to persons who only have coverage as Special Low Income Medicare Beneficiaries (SLMB) or as Qualifying Individuals I (QI1), this would be correct, but note that it is possible for a person to be eligible for both SLMB and a full Medicaid coverage program at the same time. Crossover claims policy would apply for those persons. More information can be found in the Florida Medicaid Provider General Handbook


Patients that are enrolled in a Medicare Advantage Plan still think that they have Medicaid second. What can we do to help us and them?


Florida Medicaid covers the Medicare Part C deductible and coinsurance up to the Medicaid fee, less any amounts paid by Medicare. If this amount is negative, no Medicaid payment is made. If this amount is positive, Medicaid pays the coinsurance and deductible up to the billed or allowed amount, whichever is less. The Florida Medicaid system is in the process of being programmed to comply with the state’s policy governing Medicare Advantage plan copayments. The system changes will be retroactive to January 1, 2010

Slide 38 of the presentation states that full Medicaid over-rules lower programs. Then, on slide 61 it states that as the recipient is QMB along with full Medicaid, the provider can bill for level of care (Medicare coinsurance). Could you please clarify this issue?

The QMB coverage means that the person has Medicare (another payer) in addition to the Medicaid coverage. The “level of care” refers to Nursing Facilities. Even though this person does not have the Long Term Care Medicaid, they have Medicare that could pay for Nursing Facility days (up to a limit). In this case the facility can bill Medicaid for part A coinsurance only – level of care =X. Of course, during the process of verifying eligibility, you would have already seen the Medicare coverage information.

SLMB: What is the definition of a Medicare Premium?

The Medicare premium is the amount that a person with Medicare Part A and/or Medicare Part B pays to Medicare to receive coverage.

Can you go over reimbursement for Share of Cost Medicaid patients? Is Medicaid now paying the full 20% after Medicare pays 80% of their allowed amount?

Information on Medicaid reimbursement for persons with both Medicare and Medicaid (dual eligibles) can be found in Chapter 4 of the Florida Medicaid Provider General Handbook. Claims with Medicare as the primary payer are called crossover claims. In the section labeled “Medicaid Program Limits,” you will find the information on how Medicaid reimburses crossover claims. If the Medicare payment is greater than the Medicaid payment for the same procedure, you must accept the Medicare payment as “payment in full.” You cannot “Balance Bill” or require any additional payment from the recipient.



MEDICARE PART B COINSURANCE AND DEDUCTIBLE AMOUNTS - Facility billing

The following providers are allowed to bill Medicaid for Medicare Part B coinsurance and deductible:

* Nursing Home Facilities

* County Medical Care Facilities

* Hospital Long Term Care Units

For the following revenue codes, Medicaid reimburses for any Medicare Part B coinsurance and deductible amounts, based on Medicare’s payment, up to Medicaid’s maximum amount allowed. Also, Medicaid covers the coinsurance and deductible amounts on any Medicare covered services not normally covered by Medicaid. When billing, each claim line requires a CPT/HCPCS code and the date of service (DOS).

If a beneficiary has Medicare Part B coverage and Medicare does not cover the service(s), the service(s) is considered routine nursing care.

Allowed Revenue Codes: 0270, 0272, 0274, 0275, 0276, 0300 - 0359, 0400 - 0409, 0420 - 0449, 0460, 0469, 0480 - 0489, 0610 - 0619, 0636, 0730 - 0749, 0780, 0800 - 0809, 0920 - 0929, 0940 - 0949. 8.14 OTHER SERVICE REVENUE CODES

Other service revenue codes may be billed as indicated below:

* 0160 - For dually eligible beneficiaries who wish to return to their Medicaid NF bed and refuse their Medicare SNF benefit following a qualifying Medicare hospital stay. Services for nursing facility beneficiaries requiring outpatient physical therapy, outpatient speech pathology, and outpatient occupational therapy must be provided and billed under Medicare
Part B where applicable, even if no payments are made under Medicare Part A for the nursing facility stay.

* 0410 - Oxygen (gas, equipment, and supplies) for frequent or prolonged oxygen on a daily basis (i.e., at least 8 hours per day - covered when billed by a county medical care facility or hospital long-term care unit).

The rental of a concentrator is billable by a Medical Supplier and should not be confused as needing to be billed under Revenue Code 0410.

Interim reimbursement is based on a percent of charge. Final reimbursement is calculated during the respective period’s cost settlement and is based on that period’s audited cost to charge ratio.

Medicare/Medicaid – If Medicare is being billed for the nursing facility stay, neither the nursing facility nor a medical supplier can bill Medicaid for oxygen services (i.e., gas, equipment, upplies). Oxygen services are included in the Medicare payment to the facility under Medicare’s Prospective Payment System.

* Telemedicine – To be reimbursed for the originating site facility fee, the NF must bill the appropriate telemedicine NUBC revenue code with the appropriate telemedicine procedure code and modifier. Refer to the Telemedicine Section of the Practitioner Chapter for additional information. Refer to the Additional Code/Coverage Resource Materials subsection of the General Information for Providers Chapter for additional information regarding coverage parameters.

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