Ala. Admin. Code r. 560-X-1-.14

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-1-.14 - Medicaid Payments For Medicare/Medicaid And/Or Qualified Medicare Beneficiaries (QMB) Eligible Recipients

Medicaid pays the monthly premiums for Medicare insurance for an eligible Medicare/Medicaid and/or QMB recipient to the Social Security Administration. Medicaid also pays the applicable Medicare Part A and Part B deductibles and/or coinsurance for an eligible Medicare/Medicaid and/or QMB recipient, as specified below.

(1) Definitions

(a) "QMB" recipient is a Part A Medicare beneficiary whose verified income and resources do not exceed certain levels.

(b) "Deductible" is the dollar amount a Medicare eligible must pay for his/her own health care services.

(c) "Coinsurance" is the percentage of each bill a Medicare eligible must pay under certain conditions, in addition to the deductible amount.

(2) Part A

(a) The Part A deductible less any applicable copay or coinsurance days are covered Medicaid services. For QMB recipients, the inpatient hospital deductible less any applicable copay, coinsurance days and lifetime reserve days are covered services for any inpatient admission.

(b) Medicaid may pay the Part A coinsurance for the 21st day through the 100th day for Medicare/Medicaid and/or QMB eligible recipients who qualify under Medicare rules for skilled level of care. An amount equal to that applicable to Medicare Part A coinsurance, but not greater than the facility's Medicaid rate will be paid for the 21st through the 100th day. No payment will be made by Medicaid (Title XIX) for skilled nursing care in a dual certified nursing facility for the first 20 days of care for recipients qualified under Medicare rules.

(c) Medicare pays in full for Medicare-approved home health services, therefore, Medicaid has no liability for these services.

(d) Medicare pays in full for Medicare-approved hospice services, therefore, Medicaid has no liability for these services.

(e) Medicaid covers Medicare coinsurance days for swing bed admissions for QMB recipients. An amount equal to that applicable to Medicare Part A coinsurance, but not greater than the Medicaid swing bed rate, will be paid.

(f) Medicaid will pay Part A claims in accordance with Medicaid reimbursement methodology for Medicare recipients who have exhausted their life-time Medicare benefits. Those claims must be filed directly to Medicaid in accordance with instructions in Chapter 19 of the Alabama Medicaid Provider Manual.

(3) Part B

(a) Except as provided in this subsection, Medicaid pays the Medicare Part B deductible and coinsurance to the extent of the lesser of the level of reimbursement under Medicare rules and allowances or total reimbursement allowed by Medicaid less Medicare payment.

(b) Medicare related claims for QMB recipients shall be reimbursed in accordance with the coverage determination made by Medicare. Medicare related claims for recipients not categorized as QMB recipients shall be paid only if the services are covered under the Medicaid program.

(c) Medicare claims for rented durable medical equipment shall be considered for payment if the equipment is covered as a purchase item under the Medicaid Program. Rental payments and purchases on non-covered Medicaid items for QMB recipients shall also be considered for payment.

(4) When a Medicaid recipient has third party health insurance of any kind, including Medicare, Medicaid is the payer of last resort. Thus, provider claims for Medicare/Medicaid eligibles and QMB eligibles must be sent first to the Medicare contracted intermediary. Claims paid by the Medicare contracted intermediary will be electronically forwarded to Medicaid's fiscal agent for payment of the Medicare cost-sharing charges. Claims denied by the Medicare intermediary are not forwarded to the Medicaid fiscal agent. Chapter 20 of this Code contains additional health insurance information.

(a) Providers will complete the appropriate Medicare claim forms ensuring that the recipient's 13-digit Medicaid ID number is on the form. The completed claim shall be forwarded to an Alabama Medicare carrier for payment.

(b) If the provider's claim for service is rejected by the Medicare carrier as "Medicare non-covered service" but is a covered Medicaid service, a Medicaid claim form, completed in accordance with instructions in the Alabama Medicaid Provider Manual, with a copy of the Medicare rejection statement, should be sent to the Medicaid fiscal agent for payment. QMB-Only recipients are not entitled to Medicaid coverage for Medicare non-covered services.

(c) Providers in other states who render Medicare services to Alabama Medicare/Medicaid eligibles and QMB eligibles should file claims first with the Medicare carrier in the state where the service was performed.

Ala. Admin. Code r. 560-X-1-.14

Rule effective October 1, 1982. Amended: Effective November 10, 1983; March 13, 1984; June 21, 1984; January 8, 1985; April 11, 1986; January 1, 1988. Emergency Rule: effective February 1, 1989. Amended: Effective May 12, 1989. Emergency Rule effective January 1, 1990; May 1, 1990. Amended: Effective June 14, 1990. Amended: File March 7, 1996; effective April 12, 1996. Amended: Filed October 6, 1997; effective November 10, 1997. Amended: Filed December 8, 1999; effective January 12, 2000. Amended: Filed April 9, 2010; effective May 14, 2010. Amended: Filed September 11, 2013; effective October 16, 2013.

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 09, June 30, 2015, eff. 7/16/2015.

Author: Solomon Williams, Associate Director, Institutional Services

Statutory Authority: State Plan, Attachments 3.2-A and 3.5-A; 42 C.F.R. §431.625; Social Security Act, Title XIX; Medicare Catastrophic Coverage Act of 1988 ( Public Law 100-360).