Coordinating Dual Eligibles Medicare and Medicaid Managed Medical Assistance Benefits

Transcription

1 Crdinating Dual Eligibles Medicare and Medicaid Managed Medical Assistance Benefits Medicare beneficiaries wh have limited incme and resurces may get help paying fr their Medicare premiums and ut-f-pcket medical expenses frm Medicaid. Medicaid may als cver additinal services beynd thse prvided under Medicare. Dual eligible Medicare and Medicaid recipients are eligible fr sme frm f Medicaid benefit, whether that Medicaid cverage is limited t certain csts, such as Medicare premiums, r the full benefits cvered under the Medicaid State Plan. This fact sheet prvides educatin abut cverage fr dual eligible recipients, as well as requirements under the Flrida Statewide Medicaid Managed Care prgram. Overview The Medicare prgram prvides hspital insurance (Medicare Part A) and supplementary medical insurance (Medicare Part B), either thrugh a fee-fr-service (FFS) r capitated arrangement. Original Medicare is fee-fr-service cverage where the federal gvernment pays health care prviders directly fr Medicare Part A and/r Part B benefits. Fr individuals with riginal Medicare cverage, ut-f-pcket expenses (cst-sharing) may include cinsurance, cpayments, deductibles, and premiums. Medicare Advantage plans (knwn as Medicare Part C) are als available fr recipients with Medicare Part A and B. These health plans prvide all Medicare Part A and Part B benefits, but are ffered by private cmpanies, mstly thrugh capitated arrangements. Fr individuals enrlled in a Medicare Advantage plan, cst-sharing may als include cinsurance, cpayments, deductibles, and premiums. A Dual Eligible Special Needs Plan (D-SNP) is a type f Medicare Advantage plan that is designed t prvide targeted services t Medicare recipients wh are in institutins, are dual-eligible recipients, r have a severe r disabling chrnic cnditin. Individuals wh qualify fr full Medicaid benefits are called full benefit dual eligibles. State Medicaid prgrams may cver cst sharing expenses fr full benefit dual eligibles, as well as ther health care services that Medicare des nt cver, such as mst types f lng-term care services, behaviral health, dental, etc. v Page 1 f 5

2 Flrida Statewide Medicaid Managed Care Prgram The Statewide Medicaid Managed Care prgram cnsists f tw cmpnents: the Managed Medical Assistance (MMA) prgram and the Lng-term Care (LTC) prgram. The MMA prgram prvides medical, dental, and behaviral health services t infants, children and adults n Medicaid. The LTC prgram prvides nursing facility and hme and cmmunity-based lng-term care services t elders and adults with disabilities n Medicaid wh meet nursing hme level f care. Apprximately 85% f Flrida Medicaid recipients are required t receive their health services thrugh an MMA plan. Flrida law specifies the Medicaid recipients wh cannt enrll in a plan (excluded frm participatin) and thse wh may chse t enrll in an MMA plan, but are nt required t d s. Full benefit dual eligibles, including thse enrlled in a Medicare Advantage Plan that is nt fully liable fr all Medicaid services cvered under the MMA prgram, are mandatry fr enrllment in an MMA plan. Full benefit dual eligibles enrlled in a Medicare D-SNP r a Medicare Advantage plan that is fully liable fr all Medicaid services cvered under the MMA prgram are excluded frm enrllment in an MMA plan. Dual eligible recipients whse Medicaid benefits are limited (partial duals) are excluded frm enrllment in the SMMC prgram (bth LTC and MMA). The categries that are excluded are: Qualified Medicare Beneficiaries (QMB), withut ther full Medicaid cverage; Specified Lw-Incme Medicare Beneficiaries (SLMB), withut ther full Medicaid cverage; and Qualifying Individuals (QI). Managed Medical Assistance (MMA) Plans Respnsibilities Because Medicare and the MMA prgram cver similar services fr this ppulatin, crdinatin between the tw prgrams is necessary t ensure that enrllees receive services apprpriately. This sectin prvides an verview f the requirements and expectatins fr MMA plans when crdinating a dual eligible enrllee s Medicare and MMA benefits. Authrizatin Requirements Fr dual eligibles, Medicare is the primary payer fr any medical services cvered by Medicare, and Medicaid is the payer f last resrt. If an enrllee requires a Medicare cvered service, the enrllee must fllw Medicare s service authrizatin prtcls. The MMA plan is nt respnsible fr authrizing a Medicare cvered service fr a dually eligible MMA enrllee. Primary Care Services Cvered by Medicare v Page 2 f 5

3 The MMA plan is respnsible fr ensuring that all enrllees have a primary care physician (PCP). If an enrllee des nt have r des nt chse a PCP, the plan must assign ne t the enrllee upn enrllment in the MMA plan. Hwever, if a dual eligible is already receiving primary care services thrugh Medicare, and has a PCP, the enrllee des nt have t chse a new PCP thrugh the MMA plan. If the dual eligible des nt have a PCP, the plan shuld assist the enrllee in chsing a PCP that accepts their Medicare cverage. The MMA plan cannt require the enrllee t give up his r her existing Medicare authrized PCP nr prevent the enrllee frm receiving primary care services frm their Medicare physician. Other Medical Services cvered by Medicare: When Medicare is the primary payer, the MMA plan cannt require that the enrllee chse a prvider that is a part f its netwrk in rder t receive the service. In thse instances where the enrllee is receiving a service that has limited cverage under Medicare, and Medicaid may eventually becme the primary payer (e.g., behaviral health services), the enrllee may want t chse a prvider that accepts bth Medicare and Medicaid payment. Once Medicaid becmes the primary payer: The MMA plan is respnsible fr authrizing the service using its usual MMA prgram authrizatin prtcls. The MMA plan may restrict the enrllee s chice f service prviders t thse prviders that are in the MMA plan s netwrk fr services authrized and reimbursed by the MMA plan. The MMA plan is respnsible fr crdinating the enrllee s care with Medicare and ensuring that the MMA plan des nt authrize r prvide duplicative services. Medical Services nt cvered by Medicare: Sme services cvered under the MMA prgram may nt be cvered by Medicare (e.g., dentures). In these cases, if the full benefit dual eligibles require such a service, the enrllee s MMA plan is respnsible fr authrizing the service using its usual MMA prgram authrizatin prtcls. The MMA plan may restrict the enrllee s chice f service prviders t thse prviders that are in the MMA plan s netwrk fr services authrized and reimbursed by the MMA plan. Cntracting and Payment v Page 3 f 5

4 The MMA plan is respnsible fr cvering Medicare deductibles and c-insurance payments made by the prviders r enrllees, accrding t guidelines in the Flrida Medicaid Prvider General Handbk. If the Medicare payment exceeds the Medicaid payment s that n Medicaid payment is made, then the Medicaid cpayment r cinsurance is nt paid. If the prvider has cllected the Medicaid cpayment r cinsurance frm the enrllee, the prvider must reimburse it t the enrllee. If a prvider is primarily receiving reimbursement thrugh Medicare fr the recipient s services, and is nly billing Medicaid fr any cpayments, cinsurance, r deductibles, the prvider des nt have t cntract with r enter int an agreement with the MMA plan t receive reimbursement. Hwever, the Medicare prvider will need t be fully enrlled in r be registered with the Flrida Medicaid prgram in rder t be reimbursed fr any cpayments, cinsurance, r deductibles frm the MMA plan. All Medicare prviders that currently receive Medicare crssver payments frm Medicaid are already enrlled in Medicaid and d nt need t take any actin t enrll. If the prvider is nt enrlled, please review the Flrida Medicaid Prvider General Handbk fr mre infrmatin n hw t register with Medicaid. If the prvider des nt have a cntract r agreement with the plan, the cpayment r cinsurance amunts will be calculated using the Medicaid FFS rates as published in the Medicaid fee schedules. Additinal Frequently Asked Questins 1. I am a QMB, but I d nt qualify fr Medicaid t pay fr my services. Am I cnsidered a full dual eligible, and I am required t enrll in the MMA prgram? N, if yu are a QMB, but d nt qualify fr full Medicaid benefits, yu are nt cnsidered a full benefit dual eligible and yu cannt enrll in the MMA prgram. This is als true if yu nly have QMB r SLMB cverage. In thse cases, yu cannt enrll in a Medicaid managed care plan. 2. I am a Medicare prvider, but I am nt cntracted with any f the MMA plans. If I nly need t be reimbursed fr crssver payments frm the plan, d I have t underg a credentialing prcess first? N. If a prvider will nly be requesting reimbursement fr any cst sharing amunts, the prvider des nt have t be fully enrlled r credentialed by the MMA plan. 3. If I am a Medicare prvider that des nt accept Medicaid, can I bill the dual eligible recipient fr any cst sharing amunts? Yes. After verifying that a patient is eligible fr Medicaid and prir t rendering a service, the prvider must infrm the recipient in advance that he des nt accept Medicaid payment fr the specific service t be rendered and he must infrm the v Page 4 f 5

5 recipient f their respnsibility fr charges nt cvered by Medicare. The prvider must dcument in the recipient s medical recrd that the recipient was infrmed and agrees t the service. [see the Flrida Medicaid Prvider General Handbk, page 1-7] Please nte: if the recipient is als a QMB, the prvider CANNOT bill the dual eligible recipient fr any cst sharing amunts. Under the Balanced Budget Act, QMBs are relieved f the liability t pay any Medicare cst sharing t any Medicare prviders r Medicare managed care entities, whether thse prviders participate in Medicaid r nt. Prviders r managed care entities are subject t sanctins if they charge recipients fr any cst sharing. This als applies t recipients wh are eligible fr Supplemental Security Incme (MS aid categry) and wh are als eligible fr Medicare, as they are autmatically cnsidered QMB eligible with full Medicaid. [see the Flrida Medicaid Prvider General Handbk page 3-28] 4. If Medicare is the primary payer fr the service, d we (prviders) have t btain authrizatin frm the MMA plan befre rendering services? N. Fr dual eligibles, Medicare is the primary payer fr any medical services cvered by Medicare, and Medicaid is the payer f last resrt. If an enrllee requires a Medicare cvered service, the enrllee must fllw Medicare s service authrizatin prtcls. The MMA plan is nt respnsible fr authrizing a Medicare cvered service fr a dually eligible MMA enrllee and cannt require prir authrizatin fr services fr which Medicare is the primary payer. 5. I am eligible fr Medicare (nn-qmb) and full Medicaid cverage and I am enrlled in an MMA plan. My physician, wh accepts Medicare, is nt cntracted with my MMA plan and is nt registered with the Flrida Medicaid prgram. Since my physician is nt cntracted with an MMA plan r registered with Flrida Medicaid, can my physician bill me fr any Medicare cpayments, cinsurance, and deductibles? Yes. Hwever, the prvider must infrm the enrllee in advance that he des nt accept Medicaid payment fr the specific service t be rendered. The prvider must dcument in the enrllee s medical recrd that the enrllee was infrmed and agrees t the service and any payment bligatins. 6. I am eligible fr Medicare (QMB Plus) and full Medicaid cverage. I am enrlled in an MMA plan. My physician, wh accepts Medicare, is nt cntracted with my MMA plan and is nt registered with the Flrida Medicaid prgram. Since my physician is nt cntracted with an MMA plan r registered with Flrida Medicaid, can my physician bill me fr any Medicare cpayments, cinsurance, and deductibles? N. Medicaid is respnsible fr deductible, cinsurance, and cpayment amunts fr Medicare Part A and Part B cvered services fr QMB recipients. Federal law prhibits a prvider r managed care plan frm billing a QMB recipient fr any cst sharing amunts this is knwn as balance billing. Federal law prvides that the Medicare payment and any Medicaid payment are cnsidered payment in full t the prvider fr services rendered t a QMB recipient. Prviders may nt accept QMB recipient as "private pay" in rder t bill the recipient directly. v Page 5 f 5