Rule 5160-1-05.1 | Payment for "Medicare Part C" cost sharing.
(A) For qualified medicare beneficiaries and medicaid recipients enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of the following amounts:
(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 (calculated as twenty-five per cent of the medicare maximum allowed amount).
(B) The department will not make any additional payment to the provider, or will make a payment of zero dollars, when payment for part C cost sharing is made using the method described in paragraph (A)(3) of this rule, and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid maximum allowed amount.
(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims and retention of relevant documents to support claims submitted for payment and any other business transactions in accordance with rule 5160-1-17.2 of the Administrative Code.
(D) Any costs beyond the medicare advantage plan's maximum out-of-pocket (MOOP) limit are not subject to cost sharing pursuant to 42 C.F.R. 422.100 (as in effect January 1, 2023).
Last updated July 27, 2023 at 8:36 AM
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