Wednesday 24 June 2015

How can we know Medicare crossed over the claims to Medicaid?

1.  What is meant by the crossover payment?


When Medicaid providers submit claims to Medicare for Medicare/Medicaid beneficiaries, Medicare will pay the claim, apply a deductible/coinsurance or co-pay amount and then automatically forward the claim to Medicaid. Providers will NO longer need to bill Medicaid separately for the Medicare deductible, coinsurance or co-pay amounts. 

2.  How will the crossover process work? 

New York State Medicaid will receive Medicare crossover claims from the Coordination of Benefits Contractor (COBC), Group Health Inc. (GHI).  The various Medicare payers across the State will all transmit paid claims for Medicare/Medicaid beneficiaries to GHI. GHI will transmit the claims to eMedNY.

How will I know if my Medicare claims were crossed over to Medicaid? 

Your Medicare remittance will have an indicator that will show the claim was an automatic cross over to Medicaid. When the indicator appears on the Medicare remittance you will not bill Medicaid for those clients

Will Medicare release the Medicare EOMB to the providers before the claim is crossed over to eMedNY? 

The crossover will occur at the same time the Medicare EOMB is released.  Therefore the provider will see the Medicare EOMB before they see the Medicaid remittance or the crossover payments from eMedNY.

Wednesday 17 June 2015

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 3

Qualifying Individual (QI)

A QI is an individual who:
  is entitled to Part A;
  has income that is at least 120 percent of the
  FPL, but less than 135 percent of the FPL;
  has resources that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for any QI are 100 percent federally funded and the total expenditures are limited by statute.


Full Benefit Dual Eligible (FBDE)

An FBDE is an individual who:

  is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized or home
and community-based waivers; and
  does not meet the income or resource criteria for a QMB or an SLMB.


Qualified  Disabled and Working Individual (QDWI)

A QDWI is an individual who:

  lost Medicare Part A benefits due to returning to work, but is eligible to enroll in and purchase Medicare Part A;
  does not have an income that exceeds 200 percent of the FPL;

Wednesday 10 June 2015

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 2

Dual Eligible Medicare Beneficiary Groups


See the First part for better understanding.

Qualified Medicare  Beneficiary (QMB Only)

A QMB is an individual who:
  is entitled to Medicare Part A;
  has income that does not exceed 100 percent of the Federal Poverty Level (FPL); and
  has resource that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

A QMB is eligible for Medicaid payment of Medicare premium, deductible, coinsurance, and copayment amounts (except for Part D). A QMB who does not qualify
for any additional Medicaid benefits is called a “QMB Only.”

QMB Plus

A QMB Plus is an individual who:
  meets all of the standards for QMB eligibility as described above;
  meets the financial criteria for full Medicaid coverage; and
  is entitled to all benefits available to a QMB, as well as all benefits available under the State Medicaid plan to a fully eligible Medicaid recipient.

These individuals often qualify for full Medicaid benefits by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.

Wednesday 3 June 2015

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 1

The Original Medicare Program, Title XVIII of the Social Security Act (SSA), provides hospital insurance, known as Part A coverage, and supplementary medical insurance, known as Part B coverage. Coverage for Part A is automatic for individuals age 65 or older (and for certain disabled individuals) who have insured status under Social Security or Railroad Retirement. Most individuals do not pay a monthly premium (amount paid to Medicare, an insurance company, or a health care plan for health coverage) for Part A if they or their spouse paid Medicare taxes while working. Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B does require payment of monthly premiums.


Individuals with Original Medicare generally pay:
  a deductible (a fixed amount per year for health care before Medicare pays its share);
  coinsurance (a percentage of the cost of the covered services and/or supplies); and
  may pay a copayment (fixed dollar amounts that an individual must pay when he or she uses a particular service).

Individuals with Original Medicare who desire Medicare drug coverage must join a Medicare Prescription Drug Plan.Medicare Advantage (MA) plans are also part of Medicare. These health plan options, known as Part C plans, are offered by private companies and approved by Medicare. MA plans are not supplemental insurance. These plans must provide all Part A and Part B coverage and follow rules set by Medicare, including benefit design and cost-sharing.

Medicare Cost-Sharing for Medicaid Recipients


Medicaid is a joint Federal and State program that helps pay medical costs for individuals with limited income and resources. Individuals with Medicare Part A and/or Part B, who have limited income and resources, may get help paying for their out-of-pocket medical expenses from their State Medicaid Program. These programs help individuals with Medicare save money each year. Medicare cost-sharing includes Part A and Part B premiums and, in some cases, may also include Part A and Part B deductible, coinsurance, and/or copayment.

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