Guidance released recently by the Centers for Medicare & Medicaid Services (CMS) sheds new light on an issue that has created hardships for beneficiaries and challenges for advocates trying to help them. The guidance addresses two issues: balance billing of Qualified Medicare Beneficiaries (QMBs)and payment of Medicare cost-sharing for dually eligible beneficiaries enrolled in Medicare Advantage plans. For details on the guidance see the CMS Memo 'Medicaid Cost Sharing for Medicaid Beneficiaries', as well as the supporting information in 'Balance Billing of Qualified Medicare Beneficiaries (QMB) Q & A' and 'Capitation for Medicare Cost Sharing in Medicare Advantage (MA) Plans Q & A'.

1. As a result, any health care services that a dual eligible beneficiary receives are paid first by Medicare, and then by Medicaid. For full dual eligible beneficiaries, Medicaid will cover the cost of care of services that Medicare does not cover or only partially covers (as long as the service is also covered by Medicaid).
2. To the Patient: Take your ZYPITAMAG® (pitavastatin) tablets Dual Savings Card along with your prescription to your pharmacist. Pay $0 for your first 30-day prescription. For each subsequent use, this card covers out of pocket costs that exceed $10 per month (up to a maximum of $85 off per month) on each 30-day supply.
3. The Anthem MediBlue Dual Advantage (HMO D-SNP) EA-H5422 is available to residents in Georgia, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Anthem MediBlue Dual Advantage (HMO D-SNP) is a Local HMO.

Answers is the place to go to get the answers you need and to ask the questions you want. This plan is a Dual Eligible Special Needs Plan (D-SNP) for people who have both Medicare and Medicaid. How much Medicaid covers depends on your income, resources and other factors. Some people get full Medicaid benefits. Some only get help to pay for certain Medicare costs, which may include premiums, deductibles, coinsurance, or copays.

Background

Dual Copay Program

State Medicaid agencies have legal obligations to pay Medicare cost-sharing for most 'dual eligibles' – Medicare beneficiaries who are also eligible for some level of Medicaid assistance. Further, most dual eligibles are excused, by law, from paying Medicare cost-sharing, and providers are prohibited from charging them. [1] But the particulars are complex in traditional Medicare and become even more complex when a dual eligible is enrolled in a Medicare Advantage (MA) plan. [2]

It may be helpful to think of dual eligibles in two categories: those who are Qualified Medicare Beneficiaries (QMBs) (with or without full Medicaid coverage) and those who receive full Medicaid coverage but whose incomes are above 100% of the federal poverty level, the ceiling for QMB eligibility.

For QMBs, all cost-sharing (premiums, deductibles, co-insurance and copayments) related to Parts A and B is excused, meaning that the state picks up the obligation. The state has responsibility for these payments for QMBs regardless of whether the particular service is also a Medicaid-covered service. States can, but are not required to, pay premiums for MA plans' basic and supplemental benefits.

The 'Balance Billing' Q & A referenced above answers the question, 'May a provider bill a QMB for either the balance of the Medicare rate or the provider's customary charges for Part A or B services?' with a straightforward, 'No.' The guidance continues:

Providers who bill QMBs for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing) are subject to sanctions. Providers may not accept QMB patients as 'private pay' in order to bill the patient directly, and providers must accept Medicare assignment for all Medicaid patients, including QMBs.

For non-QMB dual eligibles, [3] the state's obligation, according to guidance issued by CMS in 2007, is to pay up to the Medicaid rate for Medicaid services 'rendered by Medicaid providers' in excess of any third-party liability (such as that of traditional Medicare or an MA plan).[4] In other words, states do not have to pay if the Medicare service is not also a Medicaid service, or if the beneficiary saw a Medicare provider who is not also a Medicaid provider. In addition to this obligation, the Medicaid statute authorizes – but does not require – states to pay providers Medicare cost-sharing for at least some non-QMB dual eligibles. [5] It appears from the language of the statute that such payment could include cost-sharing for services not covered in the state Medicaid program.

What Level of Help is Available?

A 1997 addition to Medicaid law allowed (but did not require) states to limit their QMB cost-sharing obligations to their Medicaid payment for the same service or, if Medicaid did not cover the service, to a payment level they adopted in their state plan. Ipsw location mac os catalina. [6]After this change in the law, many states that had been paying at the full Medicare rate changed their payment policies to pay at their lower Medicaid rate. [7] A congressionally-mandated study of the effects of this provision of the law concluded that the reduced rates resulted in fewer doctor visits and mental health services, but did not examine the effect on health of such reductions and recommended further study of the issue. [8]No such further study has been undertaken.[9]

As if this weren’t all confusing enough, a different issue arises when, in rare instances that often involve coverage for wheelchairs, the state Medicaid payment is actually higher than the Medicare payment. The Medicaid statute does not preclude states from paying at their higher rate; in fact, it has been successfully argued in federal court that they must do so. [10] While the CMS Q&A discussed above states that providers must take assignment (i.e. not charge more than the Medicare approved rate) for all dual eligibles, the Medicare statute in fact only requires this of physicians. [11] Dual eligibles have had difficulties getting coverage for wheelchairs due to this apparently erroneous interpretation of the law.

How Does Cost-Sharing Work With Medicare Advantage Plans?

State Medicaid agency obligations to pay Medicare cost-sharing for QMBs and other dual eligible beneficiaries extend to services provided by MA plans. [12] But exactly how this works is not well understood, likely varies significantly from state to state, and may operate with little uniform methodology. In the traditional Medicare program, a provider files a claim with Medicare, then Medicare, after it has paid its portion, sends the claim to Medicaid for payment of the beneficiary’s cost-sharing. However, if a beneficiary is in an MA plan, the provider does not bill Medicare; the provider bills the plan or receives a capitated payment from the plan. There is no automatic system for billing the state.

The 'Capitation' Q&A referenced above asks and answers the question, 'When a State chooses to pay Medicare cost-sharing for dual eligibles enrolled in MA plans through capitated payments to the plan, may the State unilaterally determine the capitation rates, and are the MA plans obligated to accept that rate?'

CMS says the state can determine the rate but it must reflect, at least, the state’s Medicaid payment for the same service. It also says the MA plan does not have to accept the capitated rate offered by the state, but that plan providers must be able to submit valid claims to the State Medicaid program in order to obtain payment for the cost-sharing. It notes that this may be problematic as a provider may not be able to identify the plan payment for a particular service, presumably because the provider, itself, may have been paid a capitated rate. The Capitation Q&A reiterates the message from the Balance Billing Q&A that providers are prohibited from balance billing Medicaid beneficiaries. Finally, it states that all MA plans serving dual eligibles 'must specify in their contracts that dual eligible enrollees will not be held liable for Medicare Part A and B cost-sharing.'

Little is known about the extent to which this guidance is followed. In a 1999 survey of state practices with respect to dual eligibles, only 19 states reported paying some copayments for their dual eligibles in Medicare managed care. [13] To the knowledge of the Center for Medicare Advocacy, no follow-up survey has been done.

What Can Be Done?

Advocates report that dual eligibles are frequently charged improper cost-sharing. To the extent that providers are merely confused about their responsibilities, it will be helpful to provide them with the recent CMS guidance. To the extent they are unwilling to serve dually eligible beneficiaries if there is small or no cost-sharing payment from their state, dually eligible beneficiaries will have greater difficulty getting access to needed health care. Advocates can work with their states to increase the state’s cost-sharing payment to the full Medicare rate. Perhaps it is time for Congress to revisit the question of whether limited cost-sharing payments adversely impact beneficiaries.

For more information, contact attorney Patricia Nemore in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760 or pnemore @ medicareadvocacy.org (remove spaces).

[1]42 U.S.C. §1396a(n); Memorandum of February 27, 2008 from Gale P. Arden, Director, Disabled and Elderly Health Programs Group to All Associate Regional Administrators, Division of Medicaid and Children's Health, Subject: Medicare Cost-Sharing for Medicaid Beneficiaries, Attachment: Balance Billing of Qualified Medicare Beneficiaries (QMB) Q&A (February 27, 2008 memo)

[2]See, generally, 42 U.S.C. §1396a(n) and §1396d(p), for discussions relating to Qualified Medicare Beneficiaries (QMB) and §1396d(a), penultimate sentence for discussion of cost-sharing for non-QMB dual eligibles.

[3]While most of these beneficiaries are likely to be 'medically needy,' that is, to have incomes above those normally used to qualify for Medicaid but also to have high medical bills that reduce their incomes to a separate standard set for the 'medically needy,' some of them might also be individuals who receive a state supplement to their income that puts them above 100% FPL, but nonetheless allows them to receive Medicaid. For an excellent exposition of Medicaid eligibility categories, see National Health Law Program, 'An Advocate's Guide to the Medicaid Program,' (2001), which was available for purchase at http://www.healthlaw.org as of April 18, 2008.

[4]June 11, 2007 Memorandum from Gale P. Arden, Director, Disabled and Elderly Health Programs Group to All Associate Regional Administrators, Division of Medicaid and Children’s Health, Subject: Medicaid Obligations for Cost-Sharing in Medicare Part C Plans, Attachment. www.medicareadvocacy.orgInfoByTopicMedicareAdvantageAndHMOsMA_07_07.12.PartCCostShareMatrix.061107.pdf

[6]BBA-97, §4714, codified at 42 U.S.C. § 1396a(n). An example of the cost-sharing payment system allowed by the BBA is as follows: If Medicare allows $100 for a physician visit (and thus pays $80, or 80%), under full payment of cost sharing, the state would pay the full $20 remaining. But if the state’s rate for the same service is $80, the state will pay nothing, since Medicare has already paid the full amount of the state payment. If the state's payment were $90, the state would pay the difference between Medicare's payment and the state’s payment, or $10.

[7]See, e.g. Patricia B. Nemore, 'Variations in State Medicaid Buy-In Practices for Low-Income Medicare Beneficiaries – a 1999 Update,' prepared for the Henry J. Kaiser Family Foundation, (December 1999). From 1997 to 1999, at least 15 states reduced their payments to their Medicaid rates. (Variations in State Medicaid)

[8]Janet B. Mitchell, Ph.D. and Susan G. Haber, Sc.D., 'State Payment Limitations on Medicare Cost-Sharing: Impacts on Dually Eligible Beneficiaries and their Providers.' July 31, 2003, available at http://www.rti.org/abstract.cfm?pid=1203 (site visited April 18, 2008).

[9]The authors recently received a copy of a letter from a Tennessee oncologist declaring that he was withdrawing cancer drug treatments for several of his patients because Tennessee's Medicaid program, TennCare, refused to pay the 20% Medicare cost-sharing for the treatment.

[10] See, e.g,. Charpentier v. Belshe, Civ. No. 90-758 EJG/PAN, Medicare & Medicaid Guide (CCH) 43,123 (N.D.Cal 1994), but see Ralabate v. Wing, 1996 WL 377204, (Medicare & Medicaid Guide (CCH) 44, 550 (W.D.N.Y. 1996)

[12]Specific references to payments related to Medicare HMOs and Medicare Advantage plans are found in State Medicaid Manual §3490.12, and appeared as early as 1991. See also, Memorandum of June 30, 2000 from Director, Disabled and Elderly Health Programs Group to Associate Regional Administrators, Division of Medicaid and State Operations, Subject: Policy Memorandum on Medicaid Obligations to Pay Medicare Cost-sharing Expenses for Qualified Medicare Beneficiaries in Medicare Health Maintenance Organizations or Competitive Medicare Plans or Medicare Plus Choice Organizations – INFORMATION; June 11, 2000 memo; February 27, 2008 memo. Etrecheck. All documents are available from the authors. Contact pnemore @ medicareadvocacy.org.

[13]Variations in State Medicaid.

Overview

Historical information about copayments can be found on the 'Historical' tab

Information about copayments proposed for members in the Adult Group with income above 106% FPL, subject to approval by the Centers for Medicare and Medicaid Services can be found in the Proposed Copay Changes section of this page. More information will be posted here when available.

Dual Copay

* NOTE: Copays under this section are copays charged under Medicaid (AHCCCS). This section does not describe copay requirements under Medicare.

Some people who get AHCCCS Medicaid benefits are asked to pay copays for some of the AHCCCS medical services that they receive. Copays can be mandatory (also known as required) or optional (also known as nominal) as explained below. Some people and certain services are exempt from copays which means that no mandatory or optional copays will be charged as explained below.

Copays are not charged to the following persons:

• People under age 19
• People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services
• Individuals up through age 20 eligible to receive services from the Children's Rehabilitative Services program
• People who are acute care members and who are residing in nursing homes, or residential facilities such as an Assisted Living Home and only when the acute care member’s medical condition would otherwise require hospitalization. The exemption from copays for acute care members is limited to 90 days in a contract year
• People who are enrolled in the Arizona Long Term Care System (ALTCS)
• People who are Qualified Medicare Beneficiaries
• People who receive hospice care
• American Indian members who are active or previous users of the Indian Health Service, tribal health programs operated under P.L. 93-638, or urban Indian health programs
• People in the Breast & Cervical Cancer Treatment Program
• People receiving child welfare services under Title IV-B on the basis of being a child in foster care or receiving adoption or foster care assistance under Title IV-E regardless of age.
• People who are pregnant and throughout the postpartum period following the pregnancy
• People in the Adult Group (for a limited time*)

*For a limited time persons who are eligible in the Adult Group will not have any copays. Members in the Adult Group include persons who were transitioned from the AHCCCS Care program as well as individuals who are between the ages of 19-64, and who are not entitled to Medicare, and who are not pregnant, and who have income at or below 133% of the Federal Poverty Level (FPL) and who are not AHCCCS eligible under any other category. Copays for persons in the Adult Group with income over 106% FPL are planned and can be found on the Proposed Copay Changes tab. Members will be told about any changes in copays before they happen.

In addition, copays are not charged for the following services for anyone:

• Hospitalizations
• Emergency services
• Family Planning services and supplies
• Pregnancy related health care and health care for any other medical condition that may complicate the pregnancy, including tobacco cessation treatment for pregnant women
• Well visits and preventive services such as pap smears, colonoscopies, and immunizations
• Services paid on a fee-for-service basis
• Provider preventable services
• Services received in the emergency department

People with Nominal (Optional) Copays

Individuals eligible for AHCCCS through any of the programs below may be charged nominal copays, unless they are receiving one of the services above that cannot be charged a copay or unless they are in one of the groups above that cannot be charged a copay. Nominal copays are also called optional copays. If a member has a nominal copay, then a provider cannot deny the service if the member states that s/he is unable to pay the copay. Members in the following programs may be charged nominal copays unless they are receiving one of the services above that cannot be charged a copay or unless they are in one of the groups above that cannot be charged a copay. Members in the following programs may be charged a nominal copay by their provider:

• State Adoption Assistance for Special Needs Children who are being adopted
• Receiving Supplemental Security Income (SSI) through the Social Security Administration for people who are age 65 or older, blind or disabled
• SSI Medical Assistance Only (SSI MAO) for individuals who are age 65 or older, blind or disabled

Ask your provider to look up your eligibility to find out what copays you may have. You can also find out by calling your health plan member services representative. You can also check your health plan's website for more information.

AHCCCS members with nominal copays may be asked to pay the following nominal copays for medical services:

Detailed service codes and category description that comprise each of the above categories are outlined on the attached Document

Medical providers will ask you to pay these amounts but will NOT refuse you services if you are unable to pay. If you cannot afford your copay, tell your medical provider you are unable to pay these amounts so you will not be refused services.

Some AHCCCS members have required (or mandatory) copays unless they are receiving one of the services above that cannot be charged a copay or unless they are in one of the groups above that cannot be charged a copay. Members with required copays will need to pay the copays in order to get the services. Providers can refuse services to these members if they do not pay the mandatory copays. Mandatory copays are charged to persons in Families with Children that are no Longer Eligible Due to Earnings - also known as Transitional Medical Assistance (TMA)

Adults on TMA have to pay required (or mandatory) copays for some medical services. If you are on the TMA Program now or if you become eligible to receive TMA benefits later, the notice from DES or AHCCCS will tell you so. Ubuntu install docker command line. Copays for TMA members are listed below.

Detailed service codes and category description that comprise each of the above categories are outlined on the attached Document

The amount of total copays can not be more than 5% of the family’s total income during a calendar quarter (January-March, April-June, July-September, and October-December). If this 5% limit is reached, no more copays will be charged for the rest of that quarter. AHCCCS has a process to track cost sharing. If a member thinks that the total copays they have paid are more than 5% of the family's total quarterly income and AHCCCS has not already told them, the member should send copies of receipts or other proof of how much they have paid to:

AHCCCS
801 E. Jefferson
Mail Drop 4600
Phoenix, Arizona 85034

If a member’s income or circumstances have changed, it is important to contact the eligibility office right away.

NOTE: The information posted on this webpage describing proposed copays is being updated. AHCCCS is working with CMS to revise the State Plan Amendment for copays that AHCCCS plans to charge members in the future. This webpage, and the link to the revised State Plan Amendment, will include the updated changes to copays when they become available. AHCCCS will also provide additional public notice of the changes to copays that AHCCCS will be proposing to charge members.