Medicare/NC Medicaid

[bumbleb]

Hi all!  I bill for PT.  In NC, Medicaid does not cover PT, unless the pt is under 21.  So we w/o the 20% not paid by MCR.

We have a pt who we were seeing at the beginning of the year.  Apparently, she did not meet her MCR deductible before I filed her claims, and had almost $100 to go.  Since Medicaid covers her MCR deductible, and they normally pay us $0, does that mean we have to w/o the $100?? 

Doesn't see right...
bren

[Michele]

Doesn't seem right, but if Medicaid doesn't cover PT over 21, then they aren't going to cover the deductible either.  At least basing that on what you've told me.  You could check with Medicaid to make sure.  Or maybe Charlene knows!   

Michele

[Pay_My_Claims]

Medicaid patients can be billed for services that are NON-covered by medicaid. Medicare makes that the patients responsibility. What you have to do is notify the patient PRIOR to services, and bill them the balance. Because medicaid clients are knowledgeable about the rules, you should have them sign the statement of benefits for your records.

[Michele]

I knew Charlene knew!  Thanks   

Michele

[Pay_My_Claims]

You are more than welcome......I have had medicaid clients call EDS on me for billing them. One had BCBS and Medicaid 2ndary. BCBS paid directly to them, and they got a bill from me about going to collections. They called EDS, and they called me asking me why was I sending a medicaid client to collections. I stated because they SPENT the BCBS check that was to be applied to their balance, and we can't bill medicaid without the EOB and payment from the primary........she said ok, thanks for that. Client calls me back about how can he make arrangements to pay what BCBS paid so the balance can go to Medicaid. Ironically most of the claim went to his deductible, and the check wasn't that large. So GET THEM TO SIGN the acknowledgment and if possible, collect up front.

[bumbleb]

Thanks for the info.  They've never balance billed or collected from Medicaid pts.  I was told that years ago Medicaid did pay for PT, but now only under 21.

This pt was disabled and on Medicare and getting Medicare-Aid(?) (I forget the name right now), but that covers their deductible, the 20%, etc so she had no out of pocket due to her income level/inability to work

At this point, the therapist apparantly was up for renewal for Medicaid, and decided not to re-enroll since NC charges $100 per provider, and didn't pay them anything (they don't see peds).  So I will have to continue to w/o the 20% not covered.

Thanks~bren

[Pay_My_Claims]

MEDICARE-Aid or Medicare Qualified Beneficiary
The MEDICARE-Aid program is also referred to as the Medicare Qualified Beneficiary (MQB-Q) program. If both Medicare and Medicaid allow the service, Medicaid will pay the lesser of 1) the Medicare cost-sharing amount, or 2) the Medicaid maximum allowable for the service less the Medicare payment for providers who file institutional claims, and a percentage of the coinsurance and deductible for providers who file professional or dental claims. Medicaid will pay the lower of the copay or the Medicaid allowable for recipients enrolled in Part C, the Medicare HMO. Recipients in the MEDICARE-Aid benefit category are not eligible to enroll in CCNC/CA or PCHP.
There are two other MQB classes, MQB-B and MQB-E. The benefits for the recipient are the payment of the Part B Medicare premium and automatic eligibility for the Low Income subsidy payment for the Part D prescription drug plan.

[Pay_My_Claims]

When a non-covered service is requested by a recipient, the provider must inform the recipient either orally or in writing that the requested service is not covered under the Medicaid program and will, therefore, be the financial responsibility of the recipient. This must be done prior to rendering the service.
A provider may also bill a Medicaid recipient for the following:
• Payments for services that are made to the recipient and not the provider by either commercial insurance or Medicare
• Services not covered by Medicare if the recipient has Medicare-AID (MQB-Q) coverage Allowable Medicaid deductibles or copayments*
• Unduplicated prescriptions in excess of 11 per month unless recipient is locked in to their pharmacy of record*
• Visits in excess of the legislative annual visit limit for provider visits for the state fiscal year (July 1–June 30) (See Section 2, Recipient Eligibility)*
• The recipient’s loss of eligibility for Medicaid as defined in 10A NCAC 21B
• Part D copay