5101:3-1-05 Medicaid coordination of benefits with the medicare program (Title XVIII).

Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5101:3-9-06 of the Administrative Code.

(A) Definitions.

(1) "Medicare" is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI and/or part B) for aged and disabled persons.

(2) "Medicare Benefits" means the health care services available to the consumer through the medicare program where payment for the services are either completely the obligation of the medicare program or in part the obligation of the medicare program with the remaining payment (cost sharing) obligations belonging to the consumer, some other third party payer and/or medicaid.

(3) "Original Medicare (also known as traditional medicare)" is a health plan that pays for medicare benefits provided to beneficiaries on a fee-for-service basis.

(4) "Medicare Advantage Plan (also known as medicare part C plan)" is a managed care delivery system that includes coverage for both hospital insurance and SMI, but the delivery of health care services are contracted to and provided by an approved medicare managed care plan, preferred provider organization, private fee-for-service plans or medicare specialty plans.

(5) "Medicare Cost Sharing" means the portion of a medicare crossover claim paid by medicaid.

(6) "Dual Eligibles or Dually Eligible Consumers" are individuals who are entitled to medicare hospital insurance and/or SMI and are eligible for medicaid to pay some form of medicare cost sharing. The following is a list of dual eligibles that qualify to have medicaid pay all or part of the cost sharing portion of a paid medicare claim:

(a) "Qualified Medicare Beneficiaries without Other Medicaid (QMB Only)" are individuals entitled to medicare hospital insurance, have income of one hundred per cent of the federal poverty level (FPL) or less and resources that do not exceed twice the limit for supplemental security income (SSI) eligibility, and are not otherwise eligible for full medicaid benefits.

(b) "QMBs with Full Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance, have incomes of one hundred per cent FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(c) "Specified Low-Income Medicare Beneficiaries with Full Medicaid (SLMB Plus)" are individuals entitled to medicare hospital insurance, have income of greater than one hundred per cent FPL, but less than one hundred twenty per cent FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(d) "Medicaid Only Dual Eligibles (for example Non QMB)" are individuals entitled to medicare hospital insurance and/or SMI and are eligible for full medicaid benefits. They are not eligible for medicaid in any of the other dual eligible categories (for example QMB). Typically, these individuals need to spend down to qualify for medicaid or fall into a medicaid eligibility poverty group that exceeds the limits of other dual eligible categories.

(7) "Medicare Crossover Claim" means any claim that has been submitted to the Ohio department of job and family services (ODJFS) for medicare cost sharing payments after the claim has been adjudicated and paid by the medicare central processor, medicare carrier/intermediary or the medicare managed care plan and the medicare central processor or medicare carrier/intermediary has determined the deductible, coinsurance and/or co-payment amounts. Claims denied by the medicare carrier/intermediary or the medicare managed care plan are not considered medicare crossover claims. See paragraphs (E) and (F) of this rule for policy on services denied or not covered by medicare.

(a) "Automatic Crossover Claim" is a medicare claim submitted to ODJFS via the automatic medicare crossover process described in paragraph (B) (2)(a) of this rule.

(b) "Provider-Submitted Crossover Claim" means a medicare crossover claim submitted to ODJFS as described in paragraph (B) (2)(b) of this rule.

(B) Medicare crossover process.

(1) ODJFS will no longer accept the JFS 06780 "Medicaid Claim Billing" form (rev. 10/2001) for processing and payment of medicare crossover claims. Medicare crossover claims must meet the claim submission guidelines in accordance with rule 5101:3-1-19 of the Administrative Code.

(2) The medicare program determines the portion of medicare cost sharing, if any, due to the provider based on medicare's business rules and submits the claim for payment to ODJFS using the automatic medicare crossover process.

(a) The "Automatic Medicare Crossover Process" is the coordination of benefit (COB) process whereby the provider bills medicare for services provided to the patient who meets the criteria described in paragraphs (A)(6)(a) to (A)(6)(d) of this rule or is a dual eligible described in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the provider and electronically submits the claim to ODJFS for the medicare cost sharing amounts. Then, the provider is paid by medicaid within ninety days from the date of payment by medicare.

(b) When the automatic medicare crossover process does not work (i.e., the provider has received payment by medicare, has not received a payment from medicaid for the medicare cost sharing portion and at least ninety days has elapsed from the date of the receipt of the medicare payment), the provider may submit a medicare crossover claim directly to ODJFS. This is considered the "Provider-Submitted Crossover Claim Process."

(3) For a provider to receive reimbursement through the automatic medicare crossover process, all of the following criteria must be met:

(a) The provider must be recognized as both a medicare and medicaid provider;

(b) The provider must accept medicare assignment; and

(c) The consumer must be receiving health care benefits under the original medicare part A and part B program (i.e., the consumer is not enrolled in a medicare managed care plan). At this time ODJFS does not have payer-to-payer COB arrangements with medicare managed care plans.

(4) For medicare crossover claims, the total sum of the payments made by ODJFS, medicare and/or all other third party payers is considered payment in full and no additional payment may be requested from the consumer with the exception of medicare co-payments as specified in paragraph (E)(5) of this rule. This is true whether or not the provider normally accepts assignment under medicare.

(a) When the provider's total reimbursement from medicare and all other third party payers equals or exceeds the medicare approved (allowed/covered) amount, no additional payment will be made by ODJFS.

(b) If payment (other than the cost sharing amounts) is inadvertently received from both medicare and medicaid for the same service, the ODJFS claims adjustment unit must be notified in accordance with the provisions set forth in rule 5101:3-1-19 of the Administrative Code.

(5) Provider submitted crossover claims must be submitted timely in accordance with rule 5101:3-1-19 of the Administrative Code.

(6) Crossover claims are not subject to medicaid co-payments in accordance with rule 5101:3-1-09 of the Administrative Code.

(C) When the medicaid consumer is covered by other third party payers, in addition to medicare, medicaid is the payer of last resort. Whether or not medicare is the primary payer, providers must bill all other third party payers prior to submitting a crossover claim to ODJFS in accordance with rule 5101:3-1-08 of the Administrative Code.

(D) ODJFS will not pay for services denied by medicare for lack of medical necessity, but may pay claims denied for reasons other then medical necessity in accordance with paragraph (F) of this rule as long as the services are covered under the medicaid program. ODJFS will not pay for any service payable by, but not billed to, medicare.

(E) Reimbursement for medicare cost sharing on medicare crossover claims.

Reimbursement for medicare crossover claims is limited to the dual eligibles listed in paragraph (A)(6) of this rule.

(1) The medicaid maximum reimbursement for the medicare cost sharing of hospital inpatient, outpatient or emergency room services is set forth in rule 5101:3-2-25 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(2) The medicaid maximum reimbursement for the medicare cost sharing of nursing facility services included in the nursing facility per diem is set forth in Chapter 5101:3-3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(3) The medicaid maximum reimbursement for the medicare cost sharing of all other part B services not included in paragraph (E)(1) or (E)(2) of this rule is set forth in rule 5101:3-1-05.3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(4) The medicaid maximum reimbursement for the medicare cost sharing of all advantage plan (part C) services is set forth in rule 5101:3-1-05.1 of the Administrative Code for consumers that elected to receive medicare benefits under a medicare advantage plan.

(5) Cost sharing for medicare part D services is not reimbursable by ODJFS in accordance with rule 5101:3-9-06 of the Administrative Code. Dually eligible consumers may be required to pay medicare co-payments for prescription drugs that are covered by medicare part D.

(F) Services that are not covered by medicare must be submitted to ODJFS as a regular medicaid claim and should never be submitted as a medicare crossover claim.

With the exception of long term care nursing facilities, when the service is denied by medicare, and is also denied by medicaid with an error message indicating that the service is covered under medicare and the provider has documentation to support the service is not covered under medicare, the provider must do all of the following when requesting payment consideration from ODJFS:

(1) Submit the appropriate claim in accordance with rule 5101:3-1-19 of the Administrative Code;

(2) Attach the summary notice of medicare benefits that shows the denied medicare services, and the denial reason code with the denial reason code explanation from the medicare summary of benefits, the provider is requesting ODJFS to consider for payment;

(3) Attach a completed "JFS 06653 Medical Claim Review Request Form (rev.05/2010)"; and

(4) Submit all forms together to the address indicated on the JFS 06653 form.

(G) Long term care nursing facility providers must submit the appropriate claim in accordance with Chapter 5101:3-3 of the Administrative Code.

Effective: 08/02/2011
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.20 , 5111.262
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 1/9/89 (Emer), 4/10/89, 5/1/90 (Emer), 7/1/90, 5/30/02, 12/18/06, 7/31/09 (Emer), 10/29/09