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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.11 Medicare and Medicaid Dual Eligibility

4.11
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 Texas Medicaid as follows:
MQMB clients are eligible for coinsurance and deductible payments according to the current payment guidelines, and receive Medicaid benefits for services that are not a benefit of Medicare or exceed Medicare benefit limitations.
Medicare Part A and Part C (Noncontracted MAPs Only)
For QMB and MQMB clients who are eligible for Medicare Part A, including clients enrolled in MAPs, claims may be reimbursed to providers for the client’s Medicare coinsurance and deductible up to the Medicaid allowed amount for the service less the amount paid by Medicare.
For Medicare Part C, the coinsurance and deductible payment guidelines apply for noncontracted MAPs only.
Medicare Part B
For QMB and MQMB clients who are eligible for Medicare Part B, Texas Medicaid reimburses the lesser of the following to providers:
The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service (If this amount is less than the deductible, then the full deductible is reimbursed instead.)
If the Medicare payment is equal to, or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid does not make a payment for coinsurance.
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.
QMB clients are not eligible for Medicaid coverage for benefits that are not covered by Medicare, and QMB clients are not eligible for THSteps or CCP Medicaid benefits.
QMB and MQMB coverage guidelines do not impact clients who are living in nursing facilities and who receive a vendor rate for client care through DADS.
Claims for Medicare copayments can also be submitted to TMHP.
Refer to:
Subsection 6.12.2.2, “Health Maintenance Organization (HMO) Copayments” in Section 6, “Claims Filing” (Vol. 1, General Information) for information about HMO copayments.
for more information about filing claims for MQMBs and QMBs.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.