Provider Notice issued 06/29/10

Payment of Cost Sharing for Medicare Advantage Plan Members

The purpose of this notice is to inform providers of HFS’ responsibility regarding Medicare cost sharing.  HFS is obligated to pay Medicare Part A and B cost sharing (copayments, deductibles and coinsurance) for Qualified Medicare Beneficiary (QMB) and Dual Eligible participants. QMB and Dual Eligible participation is explained in Chapter 100, Topic 120.

In accordance with federal law (42 USC 1395cc and 42 USC 1395w-4), providers cannot charge a QMB or Dual Eligible participant for any Medicare cost sharing. The following identifies the manner by which providers may seek reimbursement for Medicare Advantage Plan cost sharing.  Medicare Advantage Plans include Health Maintenance Organization (HMOs), Preferred Provider Organizations (PPO), Private Fee-For-Service (PFFS) plans and Special Needs Plans. The participant’s Medicare health plan will be shown on their identification card. 

Medicare HMOs, PPO and Special Needs Plans

Providers rendering services to QMB and Dual Eligible participants enrolled in Medicare managed care plans, except Medicare Private Fee-For-Service (PFFS) plans, must seek payment of the participant’s cost sharing from the Medicare managed care plan. The provider’s financial arrangement with the managed care plan, including obtaining the cost sharing payments, is between those two parties.  Providers should not bill HFS for cost sharing for QMB and Dual Eligible participants enrolled in Medicare managed care plans, excluding Medicare PFFS plans.

Medicare Private Fee-For-Service (PFFS) plans

For dates of service July 1, 2009, and after,  providers may bill the department for applicable cost sharing for services rendered to QMB/Dual Eligible participants enrolled in Medicare PFFS plans as they would for any QMB or Dual Eligible enrolled in Original Medicare, Medicare's traditional fee-for-service (FFS) program. The claims submitted must be for dates of service within the twenty-four (24) month timely filing limit for Medicare crossovers.

Under Original Medicare, the majority of Medicare primary claims will crossover automatically from the Coordination of Benefits Contractor (COBC) to the department. When seeking reimbursement for participants enrolled in a PFFS, non-institutional providers will be required to submit an HFS 3797 or 837P and institutional providers will be required to submit an UB04 or 837I to the department. These claims must be completed in the same manner as Original Medicare crossover claims. The three-digit TPL Code 910 is required in conjunction with the two-digit TPL Status Code for clams submitted on the 837P.

Billing questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565. Questions from managed plans regarding their financial relationship with the department may be directed to the Bureau of Pharmacy Services at 217-524-7112. 

Theresa A. Eagleson, Administrator

Division of Medical Program