Medicaid’s Medicare Advantage Managed Care Plan

Does Medicaid cover Medicare advantage plan copay, deductible?

Medicaid’s Medicare Advantage Managed Care Plan

There are currently four companies who contract with the Alabama Medicaid Agency and offer Medicare Advantage coverage in Alabama – United HealthCare’s Medicare Complete, Viva Health’s VIVA Medicare Plus and Blue Cross/Blue Shield of Alabama’s Blue Advantage and Windsor Health Care. 

When one of these companies notifies Medicaid that a Medicaid recipient has enrolled in their Medicare Advantage Plan, Medicaid makes a premium payment to the applicable plan. This payment covers all Medicare coinsurance and deductibles. Therefore, neither Medicaid nor the recipient will pay any co-payments, coinsurance or deductibles for Medicare services incurred during the time that the individual is enrolled in Medicaid’s Medicare Advantage Plan.

Claims can be submitted to Medicaid for copays, deductibles or coinsurances for dates of service that are prior to or after the dates that Medicaid has paid a premium to one of the four Plans listed above. These claims should be billed on a Medicare/Medicaid crossover claim and will be processed like any other Medicare paid claim. (See Section 5.7.1 for specific billing instructions)

There are several Medicare Advantage Plans that are servicing Medicaid recipients. However, the four Plans mentioned above are the only ones with whom Medicaid has a contract to pay premiums. Since Medicare Advantage Plans pay in place of Medicare, any secondary claims to Medicaid for copays, deductibles or coinsurance should be billed on a Medicare/Medicaid crossover claim and will be processed by Medicaid in the same manner as a Medicare paid claim. (See Section 5.7.1 for specific billing instructions) 

The eligibility response from AVRS or Provider Electronic Solutions provides the following information if the recipient is enrolled in a Medicare Advantage

Plan for which Medicaid is making a capitation payment:

• Verification of the recipient’s enrollment in a Medicare Advantage Plan

• Plan telephone number

Claims for services covered under this plan must be filed directly to the applicable Medicare Advantage Plan.

Basic billing question on Medicaid Managed care

MANAGED CARE

How do we find out which network provider to call?

If you check eligibility through the web portal, look for this information in the Managed Care section of the recipient’s eligibility screen. You will find the name, type and phone number of the HMO, PSN or other managed care plan.

Is the network provider the one who is going to give us the authorization for the services?

No, you would get the authorization from the Health Plan. The only time you will get authorization from a provider is for a person managed under MediPass.

Referring to Slide 50: If recipients don’t have managed care, will it be blank or will it state FL Medicaid? 

If the recipient does not have managed care, the Web Portal screen will show ***No rows found.

A patient will come in with a Medicare managed plan yet also show us a Medicaid card. The Medicaid eligibility will show full Medicaid benefits but does not show the Medicare Advantage plan yet we do call and verify eligibility with the Medicare HMO. Does Medicaid pay as a secondary in this case?

Medicaid is not currently paying crossover claims for beneficiaries in Medicare HMOs (Part C plans), but there are changes in the works that may take place as soon as the end of the year. Please watch for any upcoming provider alerts on this subject. You may also contact your Local Medicaid Area Office for questions on this topic. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/

If I have a situation where our claims are being underpaid with our HMO contract and we have sent several requests, spreadsheets and calls to get this rectified; what other recourse do we have as a provider?

The Medicaid contract requires that the provider address any claims/billing disputes through the provider complaint system of the individual Health Plan. Language from the contract is provided below. If the provider is unable to resolve this with the Health Plan, they are able to access an outside claims arbitrator, Maximus, which deals with claims disputes between Health Plans and providers. Application forms and instructions on how to file claims are available from Maximus.

How can I check for eligibility for a specific service by a managed care plan?

You may ask the recipient’s managed care plan when you contact them for authorization. If you do not have a specific recipient, you may contact the managed care plan for general information. Your Area Medicaid office may be able to provide the contact telephone numbers for the managed care plans in your county. 

Medicare rejection CO 24 - covered by Advantage plan

We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.

• Medicare claims must be submitted to the MA plan.

• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.

• Obtain eligibility and benefit information prior to rendering services to patients.

• Ask patients if they have recently enrolled in any new health insurance plans.

• Request to see a copy of all of their health insurance cards.

• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify the beneficiary's eligibility prior to submitting claims to First Coast.

• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).

• Claims that are returned as unprocessable cannot be appealed, for more information click here.

End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/index.html

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.