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2012 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 4. STAR+PLUS Program : 4.1 STAR+PLUS Program Clients : 4.1.1 STAR+PLUS Program Dual-Eligible Clients

Many STAR+PLUS clients are eligible for Medicaid and Medicare. STAR+PLUS MCOs are not at risk for the delivery of acute care services needed by dual-eligible clients.
Most STAR+PLUS clients with Medicare and Medicaid are Medicaid Qualified Medicare Beneficiaries (MQMBs). MQMBs receive Medicare benefits through a Medicare risk product (MCO) or Medicare fee-for-service insurance program. To reduce confusion, HHSC has mandated that STAR+PLUS MQMBs continue to receive all their acute care services as they do today, with Medicare being the primary payor and Texas Medicaid fee-for-service, through TMHP, the secondary payor.
MQMBs qualify for the following:
Medicaid payment of Medicare deductible and coinsurance. Medicaid may reimburse the deductible and coinsurance up to the lesser of the billed amount or the Texas Medicaid allowed amount minus the Medicare payment.
Providers are to continue billing for Medicare acute care services through the client's Medicare MCO or fee-for-service insurer following the rules of the Medicare insurer. If the client is in both a Medicare MCO and a Medicaid MCO, the client uses the Medicare PCP, and providers follow the Medicare MCO's medical management rules for authorization, concurrent review, etc. MQMBs choose a Medicaid MCO but do not choose a Medicaid PCP.
HIPP Program clients access their benefits through Texas Medicaid fee-for-service, and are not enrolled in managed care unless they choose to leave the HIPP program.
Refer to:
Subsection 4.11, “Medicare and Medicaid Dual Eligibility” in Section 4, "Client Eligibility" (Vol. 1, General Information) for more information and further MQMB instructions.
Subsection 4.14, “Health Insurance Premium Payment (HIPP) Program” in Section 4, "Client Eligibility" (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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