Title: Section 360-7.7 - Payments of deductibles and coinsurance under title XVIII of

360-7.7 Payments of deductibles and coinsurance under title XVIII of the Social Security Act (Medicare). (a) The MA program will pay on behalf of qualified Medicare beneficiaries, as defined in subdivision (g) of this section, the full amount of any deductible and coinsurance costs incurred under Part A or B of Title XVIII of the Social Security Act (Medicare).

(1) The MA program will pay the full amount of such deductible and coinsurance costs for care, services or supplies included in the MA program and for care, services or supplies that are included in the MA program.

(2) The MA program will pay the full amount of such deductible and coinsurance costs for qualified Medicare beneficiaries who are otherwise eligible for MA and for qualified Medicare beneficiaries who are not otherwise eligible for MA.

(b) The MA program will pay on behalf of MA recipients who are also eligible for benefits under Part A or B of Title XVIII (Medicare), but who are not qualified Medicare beneficiaries, the full amount of any deductible or coinsurance costs incurred under such part provided that the costs were incurred for care, services and supplies included in the MA program.

(c) Before the MA program will pay any Medicare Part B deductible or coinsurance liability, the MA recipient or qualified Medicare beneficiary must assign to the provider any Part B benefit payment to which he or she is entitled. A provider of a Medicare Part B benefit must accept assignment from such recipient or beneficiary of his or her right to receive the Medicare Part B payment.

(d) A provider of a Medicare Part B benefit must not seek to recover any Medicare Part B deductible or coinsurance amounts from an MA recipient or qualified Medicare beneficiary.

(e) To be paid for transportation services that are not paid through the Medicaid Management Information System, a provider must submit to the social services district bills for deductible and coinsurance amounts and the explanations of benefits form issued by the Medicare carrier. A provider does not have to submit the explanation of benefits form to a district which can obtain this information from the Medicare Part B fiscal agent's computer files. A district must apply Medicare Part B benefits before making MA payments for claims.

(f) Reimbursement is not available under the MA program for services or supplies furnished pursuant to Title XVIII of the Social Security Act (Medicare) if:

(1) the provisions of such title or the regulations promulgated to implement such title preclude a provider of such services or supplies from charging a Medicare beneficiary for the cost of the supplies or services provided; or

(2) the provider agrees, under the terms of a Medicare provider agreement, not to charge an individual for the cost of services or supplies.

(g) Qualified Medicare beneficiaries. (1) As used in this section and section 360-7.8 of this Subpart, the term qualified Medicare beneficiary means a person:

(i) who is entitled to hospital insurance benefits under Medicare Part A;

(ii) whose income does not exceed 100 percent of the poverty line, as defined in section 360-1.4 of this Part, applicable to a family of the size involved;

(iii) whose resources do not exceed twice the maximum amount of resources that the person may have to be eligible for Supplemental Security Income benefits; and

(iv) who meets the non-financial eligibility requirements contained in Subpart 360-3 of this Part.

(h) Qualified disabled and working individuals. As used in this section and section 360-7.8 of this Subpart, the term qualified disabled and working individual means a person who is not otherwise eligible for medical assistance and:

(1) who is entitled to hospital insurance benefits under section 1818A of Part A of Title XVIII of the Social Security Act;

(2) whose income does not exceed 200 percent of the official Federal poverty line applicable to the person's family size; and

(3) whose resources do not exceed twice the maximum amount of resources that an individual or a couple, in the case of a married individual, may have and obtain Federal supplemental security income benefits under Title XVI of the Federal Social Security Act, as determined for purposes of that program.

(i) Specified low income Medicare beneficiaries. As used in this section and section 360-7.8 of this Subpart, the term specified low income Medicare beneficiary means a person:

(1) who would be a qualified Medicare beneficiary as defined in 360-7.7(g) of this Subpart except that the person's income exceeds the regulatory income requirements; and

(2) whose income is greater than 100 percent of the official federal poverty line applicable to the person's family size but, in calendar years 1993 and 1994, is less than 110 percent of such poverty line and, in calendar years beginning in 1995, is less than 120 percent of such poverty line.

 

Volume

VOLUME A-1 (Title 18)

up