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.

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