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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 4 Federally Qualified Health Center (FQHC) : 4.4 Claims Filing and Reimbursement : 4.4.2 Reimbursement : 4.4.2.1 Medicare Crossover Claims Pricing

4.4.2.1
For Medicare Part B cost sharing obligations, all deductible obligations will be reimbursed at 100 percent of the deductible amount owed, even if the cost sharing comparison results in a lower payment. For all other cost sharing obligations (including Medicare Part A, B, and C), the cost sharing comparison is performed according to current guidelines.
For FQHC Medicare crossover claims, Texas Medicaid will reimburse the lesser of the following:
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 will not make a payment for coinsurance.
The client has no liability for any balance or Medicare coinsurance and deductible related to Medicaid-covered services.
Refer to:
Subsection 2.7, “Medicare Crossover Claim Reimbursement” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol.1 General Information).

Texas Medicaid & Healthcare Partnership
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