| (a) If a Medicaid recipient is eligible for Medicare
coverage (a dual eligible), the Health and Human Services Commission
(HHSC) or its designee pays the recipient's Medicare deductible and
coinsurance as specified in this section. Payment of deductible and
coinsurance is subject to the reimbursement limitations of the Texas
Medical Assistance Program (Medicaid).
(1) For qualified Medicare beneficiaries as defined
in the Social Security Act, §1905(p), HHSC or its designee pays
on valid Medicare claims the recipient's Part A and Part B deductible
and coinsurance as specified in this section. Payments for benefits
for individuals eligible for Medicaid only as qualified Medicare beneficiaries
are limited to payments for Medicare deductible and coinsurance as
described in subsection (b) of this section. Physicians must accept
Medicare assignment for Medicaid payment of Part B deductible and
coinsurance.
(2) For Medicaid recipients who are not qualified Medicare
beneficiaries, but for whom HHSC otherwise has Part A and Part B deductible
or coinsurance liabilities, HHSC or its designee pays the recipient's
Part B deductible on valid, assigned Medicare claims. Payment of the
recipient's Part B coinsurance and Part A deductible and coinsurance
on valid, assigned Medicare claims is limited to claims for services
that:
(A) are within the amount, duration, and scope of Medicaid;
and
(B) would be covered by Medicaid, when the services
are provided, if Medicare did not exist.
(b) Except as otherwise specified in subsections (c)
and (d) of this section, the payment of the Medicare Part A, Part
B, or Part C (for Medicare health plans not contracted with HHSC)
deductible and coinsurance is based on the following.
(1) If the Medicare payment amount equals or exceeds
the Medicaid payment rate, HHSC does not pay the Medicare deductible
and coinsurance on a crossover claim.
(2) If the Medicare payment amount is less than the
Medicaid payment rate, HHSC pays the Medicare deductible and coinsurance
on a crossover claim, but the amount of payment is limited to the
lesser of the deductible and coinsurance or the amount remaining after
the Medicare payment amount is subtracted from the Medicaid payment
rate.
(c) HHSC enters into state agreements with Part C Medicare
Advantage Plans whereby HHSC will pay the plans a monthly capitated
payment. In exchange, the plans will pay health care providers the
Medicare cost sharing obligations attributable to dual eligible members.
A health care provider who provides services to a dual eligible member
enrolled into a Medicare Advantage Plan with a state agreement must
seek payment for the member's Medicare deductible and coinsurance
from the participating plan. The health care provider must not seek
payment for the member's Medicare deductible and coinsurance from
HHSC.
(d) If HHSC has determined that higher payment for
a Medicaid service is necessary to ensure adequate access to care
or is more cost-effective to the state, HHSC may pay the Medicare
deductible and coinsurance on a crossover claim at a higher amount
than specified in subsection (b) of this section, not to exceed the
greater of the deductible and coinsurance or the amount remaining
after the Medicare payment amount is subtracted from the Medicaid
payment rate for services. HHSC may do so only where the higher payment
has been approved by the Centers for Medicare and Medicaid Services,
as specified in the Medicaid State Plan.
(e) Coverage of a recipient's deductible and coinsurance
as specified in this section satisfies HHSC's or its designee's obligation
to provide coverage for services that would have been paid in the
absence of Medicare coverage.
|
| Source Note: The provisions of this §354.1143 adopted to be effective January 1, 1989, 14 TexReg 697; amended to be effective April 1, 1990, 15 TexReg 1840; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 1, 1998, 23 TexReg 8682; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective January 1, 2012, 36 TexReg 9282; amended to be effective July 1, 2012, 37 TexReg 4575 |
