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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.11 Medicare and Medicaid Dual Eligibility : 4.11.4 Medicare Part C

4.11.4
Providers can receive information about a client’s Medicare Part C eligibility through TexMedConnect or EDI. In response to an eligibility inquiry, providers receive the client’s Medicare Part C eligibility effective date, end date, and add date.
HHSC contracts with some Medicare Advantage Plans (MAPs) and offers a per-client-per-month payment. The payment to the MAP includes all costs associated with the Medicaid cost sharing for dual-eligible clients. MAPs that contract with HHSC will reimburse providers directly for the cost sharing obligations that are attributable to dual-eligible clients enrolled in the MAP. These payments are included in the capitated rate paid to the HMO and must not be billed to TMHP or a Medicaid client.
TMHP now processes certain claims for clients enrolled in a Medicare Advantage Plan (Part C).
Refer to:
A list of MAPs that have contracted with HHSC is available in the “EDI” section of the TMHP website at www.tmhp.com. The list will be updated as additional plans initiate contracts.

Texas Medicaid & Healthcare Partnership
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