Medicare Dual Eligible Members

Medicare Dual Eligible Members (EmblemHealth Billing Guides)

Medicare Dual Eligible Members are individuals with both Medicare and Medicaid coverage. Depending on their category of Medicaid coverage, a dual eligible may receive state Medicaid plan assistance to cover their Medicare Part B premium, Medicare Parts A and B cost-share and certain benefits not covered by Medicare.

Centers for Medicare & Medicaid Services (CMS) guidelines stipulate that dual eligibles who qualify to have their Medicare parts A and B cost-share covered by their state Medicaid plan are not responsible for paying their Medicare Advantage plan cost-shares for covered services. Providers may not balance bill for these amounts.

To comply with this CMS requirement, providers treating dual eligibles enrolled in an EmblemHealth Medicare Advantage plan must do the following for these members:

  • Bill┬áthe Managing Entity as primary payor and the state Medicaid plan as secondary payor
  • Accept the Medicaid payment as payment in full and not collect any cost-share from the member if they participate with their state Medicaid program
  • Prior to providing services, notify the member if they do not accept the state Medicaid as payment in full

Effective January 1, 2016, Medicaid will no longer reimburse partial Medicare Part B coinsurance amounts when the Medicare payment exceeds the Medicaid fee or rate for that service. If the Medicare payment is greater than the Medicaid fee, no additional Medicaid payment will be made.

Effective July 1, 2016, Medicaid will no longer pay the full copayment or coinsurance amounts for Medicare Part C claims. Medicaid will reimburse at the rate of 85 percent of the Medicare Part C copayment or coinsurance amount.

These changes also apply to pharmacy claims for medications and supplies. There is no change to the current reimbursement methodology of Medicare Part B coinsurance or Part C copayment/coinsurance for ambulance providers, psychologists, or Federally Qualified Health Centers (FQHCs). These providers will continue to be paid the full Medicare Part B coinsurance and Part C copayment/coinsurance amounts.

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