CBIC - Round 1 Recompete - Dual Eligibles FAQs, CBIC - Round 2 - Dual Eligibles FAQs

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Dual Eligibles FAQs

Can suppliers charge QMBs, including QMB Plus beneficiaries, for Medicare cost-sharing under the competitive bidding program? No. The amount of payment made by Medicare plus the amount of payment made under the Medicaid State Plan (if any) is payment in full for the service. If you try to collect more than the amounts paid by Medicare and Medicaid, you could be subject to sanctions.	04/02/2014
How can suppliers identify what type of dual eligible beneficiary they are dealing with? Suppliers have several methods to determine the type of dual a beneficiary is. First, all dual eligible beneficiaries receive a letter of eligibility from the State Medicaid agency explaining their eligibility benefits. Suppliers should request this letter when dealing with the beneficiary. Some states issue a Medicaid eligibility card explaining the type of Medicaid coverage for which the beneficiary is eligible. This card usually has the beneficiary’s name along with other identifying information detailing the type of beneficiary. Finally, a State’s Medicaid Management Information System (MMIS) has a provider accessible means (either electronic or phone) which allows providers using beneficiary information (found on the beneficiary’s letter of eligibility or card) to verify the type of beneficiary along with the Federal/State approved Medicare/Medicaid eligibility for the beneficiary. This electronic/phone system would only be accessible by providers who have enrolled in the State’s Medicaid program for purposes of payment.	04/02/2014
How will suppliers be reimbursed for Medicare cost-sharing for QMB and QMB Plus beneficiaries? Each state Medicaid program is legally responsible for paying suppliers for any Medicare cost-sharing that is due for QMBs and QMB Plus beneficiaries, according to its CMS-approved Medicare cost-sharing payment methodology. Federal law gives states the authority to pay cost-sharing for QMBs and QMB Plus beneficiaries at the Medicare cost-sharing amount, the Medicaid State Plan rate for the same service, or a rate between those amounts that is established by the state and approved by CMS. States are allowed to limit payment for QMB and QMB Plus cost-sharing to the amount necessary to provide a total payment to the supplier (including Medicare, Medicaid, required nominal Medicaid co-payments, and third party payments) equal to the amount a state would have paid for the service under the State Plan. When the cost-sharing claim is for Medicare-covered services that are not included in the Medicaid State Plan, the state is still liable to pay the cost-sharing claim, but may establish reasonable payment limits, approved by CMS, for the service. To receive payment, DMEPOS contract suppliers must enroll as a State Medicaid provider with each state in their service area. Contact information for each State’s Medicaid program is available at www.medicaid.gov.	04/02/2014
What are the different types of dual eligible beneficiaries, and what does Medicaid pay for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) for each type? There are 7 different types of dual eligible beneficiaries. However, out of the 7 types only the 4 types identified below are provided actual Medicare cost-sharing benefits from Medicaid. The other 3 types receive Medicaid payment of Medicare premiums only. Qualified Medicare Beneficiary (QMB) A QMB is a person who is entitled to Medicare Part A and is eligible for Medicare Part B; has an income that does not exceed 100 percent of the Federal Poverty Level (FPL), and whose resources do not exceed twice the Supplemental Security Income (SSI) limit. A QMB who does not qualify for any additional Medicaid benefits is referred to as “QMB Only”. Medicaid pays Medicare cost-sharing amounts only for Medicare-covered DMEPOS. If Medicare denies payment, Medicaid will not pay for the DMEPOS. QMB Plus A QMB Plus is a person who meets all of the standards for QMB eligibility and also meets the financial criteria for another Medicaid coverage group. Such individuals are entitled to all benefits available to a QMB, as well as all benefits available under the State Plan to a fully eligible Medicaid recipient. Medicaid pays Medicare cost-sharing amounts only for Medicare-covered DMEPOS. If Medicare doesn’t cover the DMEPOS, but the Medicaid State Plan does, Medicaid will pay for the DMEPOS, subject to limitations established in the State Plan, when the beneficiary obtains the item or service from a Medicaid-participating provider. Specified Low Income Medicare Beneficiaries (SLMB) Plus A SLMB Plus is an individual who meets the standards for SLMB eligibility, but who also meets the financial criteria for another Medicaid coverage group. If Medicare doesn’t cover the DMEPOS, but the Medicaid State Plan does, Medicaid will pay for the DMEPOS, subject to limitations established in the State Plan, when the beneficiary obtains the item or service from a Medicaid-participating provider. Full Benefit Dual Eligible (FBDE) A FBDE is an individual who meets the standards for Medicaid but does not meet the income or resource criteria for a QMB or a QMB Plus beneficiary. The FBDE Medicaid income/resource eligibility criteria are different from the criteria for SLMB Plus. These eligibility criteria determine Medicaid benefits and establish the Medicare cost-sharing benefits for the beneficiary. If Medicare doesn’t cover the DMEPOS, but the Medicaid State Plan does, Medicaid will pay for the DMEPOS, subject to limitations established in the State Plan, when the beneficiary obtains the item or service from a Medicaid-participating provider. Medicaid will also pay the Medicare cost-sharing related to payment of premiums, deductibles and Medicare co-pays.	04/02/2014
Where can I find more information about dual eligible beneficiaries? For more information about QMBs and other individuals who are dually eligible to receive Medicare and Medicaid benefits, please refer to the Medicare Learning Network® publication titled “Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles),” which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf For additional information, please review: The Center for Medicaid and CHIP Services (CMCS) Informational Bulletin; 08/02/2013 - DMEPOS Competitive Bidding The Center for Medicaid and CHIP Services (CMCS) Informational Bulletin; 07/07/2013 - Payment of Medicare Cost Sharing for Qualified Medicare Beneficiaries (QMBs) MLN Matters - Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)	04/02/2014

last updated on 04/02/2014

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