1 Tex. Admin. Code § 354.1143 - Coordination of Medicaid with Medicare Parts A, B, and C
(a) If a Medicaid recipient is eligible for
Medicare coverage (a dual eligible), the Health and Human Services Commission
(HHSC) or its designee pays the recipient's Medicare deductible and coinsurance
as specified in this section. Payment of deductible and coinsurance is subject
to the reimbursement limitations of the Texas Medical Assistance Program
(Medicaid).
(1) For qualified Medicare
beneficiaries as defined in the Social Security Act, §1905(p), HHSC or its
designee pays on valid Medicare claims the recipient's Part A and Part B
deductible and coinsurance as specified in this section. Payments for benefits
for individuals eligible for Medicaid only as qualified Medicare beneficiaries
are limited to payments for Medicare deductible and coinsurance as described in
subsection (b) of this section. Physicians must accept Medicare assignment for
Medicaid payment of Part B deductible and coinsurance.
(2) For Medicaid recipients who are not
qualified Medicare beneficiaries, but for whom HHSC otherwise has Part A and
Part B deductible or coinsurance liabilities, HHSC or its designee pays the
recipient's Part B deductible on valid, assigned Medicare claims. Payment of
the recipient's Part B coinsurance and Part A deductible and coinsurance on
valid, assigned Medicare claims is limited to claims for services that:
(A) are within the amount, duration, and
scope of Medicaid; and
(B) would be
covered by Medicaid, when the services are provided, if Medicare did not
exist.
(b)
Except as otherwise specified in subsections (c) and (d) of this section, the
payment of the Medicare Part A, Part B, or Part C (for Medicare health plans
not contracted with HHSC) deductible and coinsurance is based on the following.
(1) If the Medicare payment amount equals or
exceeds the Medicaid payment rate, HHSC does not pay the Medicare deductible
and coinsurance on a crossover claim.
(2) If the Medicare payment amount is less
than the Medicaid payment rate, HHSC pays the Medicare deductible and
coinsurance on a crossover claim, but the amount of payment is limited to the
lesser of the deductible and coinsurance or the amount remaining after the
Medicare payment amount is subtracted from the Medicaid payment rate.
(c) HHSC enters into state
agreements with Part C Medicare Advantage Plans whereby HHSC will pay the plans
a monthly capitated payment. In exchange, the plans will pay health care
providers the Medicare cost sharing obligations attributable to dual eligible
members. A health care provider who provides services to a dual eligible member
enrolled into a Medicare Advantage Plan with a state agreement must seek
payment for the member's Medicare deductible and coinsurance from the
participating plan. The health care provider must not seek payment for the
member's Medicare deductible and coinsurance from HHSC.
(d) If HHSC has determined that higher
payment for a Medicaid service is necessary to ensure adequate access to care
or is more cost-effective to the state, HHSC may pay the Medicare deductible
and coinsurance on a crossover claim at a higher amount than specified in
subsection (b) of this section, not to exceed the greater of the deductible and
coinsurance or the amount remaining after the Medicare payment amount is
subtracted from the Medicaid payment rate for services. HHSC may do so only
where the higher payment has been approved by the Centers for Medicare and
Medicaid Services, as specified in the Medicaid State Plan.
(e) Coverage of a recipient's deductible and
coinsurance as specified in this section satisfies HHSC's or its designee's
obligation to provide coverage for services that would have been paid in the
absence of Medicare coverage.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.