(A) For qualified medicare beneficiaries and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of:
(1) The provider's billed charges for the service (except for hospital and nursing facility services); or
(2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or
(3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or
(4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B.
(B) This payment arrangement applies to qualified medicare beneficiaries and medicaid consumers enrolled in a medicare part C plan.
(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment.
(1) Providers submitting medicare part C crossover claims to the medicaid program must be able to provide upon request documentation that supports that the information provided on the claim matches the information on the part C plan's remittance advice.
(2) Providers submitting medicare part C crossover claims to the medicaid program who are paid under a capitation arrangement with the medicare part C plan, and do not submit claims to the plan for services rendered, must be able to provide upon request documentation of the capitation arrangement including specific details about the plan's cost sharing requirements.
Five Year Review (FYR) Dates: 08/05/2014 and 11/09/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 5-14-04 (Emer.) ; 7-30-04