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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.13 Medicare Claims

6.13
Medicaid clients who are also eligible for Medicare Part A (inpatient coverage), Part B (medical coverage), or Part C (noncontracted Medicare Advantage Plans [MAPs]), may be covered by Medicaid as follows:
Qualified Medicare beneficiary (QMB). QMB clients are covered by Medicare through Part A, B, or C coverage. Medicaid may reimburse providers for the client’s Medicare coinsurance and deductible up to the Medicaid allowed amount for the service less the amount paid by Medicare.
Medicaid Qualified Medicare beneficiary (MQMB). MQMB clients are covered by Medicare through Part A, B, or C coverage and receive Medicaid benefits for services that are not a benefit of Medicare or exceed Medicare benefit limitations. Medicaid also may reimburse providers for the client’s Medicare coinsurance and deductible up to the Medicaid allowed amount for the service less the amount paid by Medicare.
Note:
If the Medicare payment is equal to or exceeds the Medicaid allowed amount or encounter payment for the service, no additional payment is made for coinsurance and deductible.
For Medicare Part C, the above coinsurance and deductible payment guidelines apply for noncontracted MAPs only.
Claims for Medicare copayments can also be submitted to TMHP.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.