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25.1.4 Medicaid Relationship to Medicare
The Texas Medicaid Program makes coinsurance and deductible payments on valid, assigned Part A (hospital) and Part B (medical) Medicare claims.
Exception: If the Medicare payment amount equals or exceeds the Medicaid payment rate, HHSC is not required to pay the Medicare Part A and/or Part B deductible/coinsurance/copay on a crossover claim.
The Texas Medicaid Program provides 30 inpatient benefit days per spell of illness. When the 30 days coincide with the first 30 days of the Medicare benefit period and the client is eligible for both Medicare and Medicaid, the Texas Medicaid Program pays the:
• Inpatient hospital deductible under Medicare Part A.
•Medicare Part A deductible for the first three pints of whole blood or packed red cells.
When the client only has Medicare Part B coverage, the hospital must follow these guidelines:
•Submit to Medicare the charges for certain inpatient ancillary services on a Medicare Claim Form 1483 for payment under the client's Part B coverage. The ancillary charges include the following:
•Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests.
•X-ray, radium, and radioactive isotope therapy, including materials and services of technicians.
•Surgical dressings, splints, casts, and other devices used for reduction of fractures and dislocations.
•Prosthetic devices (other than dental) that replace all or part of an internal body organ or member (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ or member including replacement or repairs of such devices (e.g., cardiac pacemakers, breast prostheses, maxillofacial devices, colostomy bags, and prosthetic lenses).
•Leg, arm, back and neck braces, and artificial legs, arms, and eyes, including replacements and adjustments (if required) because of a change in the client's physical condition.
•Physical therapy (PT) services.
•Speech pathology services.
•Dialysis treatments.
•Submit to TMHP the remaining Part A charges on a UB-04 CMS-1450 claim form (or its electronic equivalent) indicating in Block 80 that the client is eligible for Medicare Part B benefits only. The client's health insurance claim (HIC) number must appear on the Medicaid claim in Block 80. TMHP must receive these charges within 95 days of the last date of service on the claim.
Refer to: "Medicare Crossover Reimbursement" for more information.
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