Provider Notice issued 06/19/15

Payment of Cost Sharing for Medicare Advantage Plan (MAP) Members Effective July 1, 2015

The purpose of this notice is to inform providers of a new Healthcare and Family Services (HFS) policy concerning Medicare cost sharing for Medicare Advantage Plan (MAP) Members (also known as Medicare Replacement Policies).  In a Provider Notice dated June 29, 2010 to All Participating Medical Assistance Providers, HFS notified providers to seek Medicare cost sharing from the MAP for individuals enrolled in MAPs and Medicaid unless the plan was a Medicare Private Fee-For-Service (PFFS) Plan. 

For dates of service July 1, 2015 and after, providers may bill the department for Medicare co-insurance and deductibles for individuals enrolled in a Medicare Advantage Plan and Medicaid.  HFS will consider cost-sharing when the participant is a Qualified Medicare Beneficiary (QMB) with or without Medicaid full benefits.  Additional information regarding the QMB program can be found on the QMB Medicare Savings Programs webpage.  

Claims from MAPs do not automatically cross over to the department.  Providers must submit claims within the twenty-four (24) month timely filing limit for Medicare crossovers.  Providers should review the Explanation of Medicare Benefits to determine if the client has co-insurance and deductibles.  Non-Institutional providers are required to submit a paper HFS 3797, Medicare Crossover or 837P and institutional providers will be required to submit a paper UB04 or 837I to the department.  Claims must be completed in the same manner as original fee-for-service Medicare crossover claims.  The appropriate three digit TPL code 909 or 910 is required in conjunction with the two digit TPL Status Code.

Billing questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services and the Bureau of Hospital and Provider Services at

1-877-782-5565.

Felicia F. Norwood

Director