Dual Eligible Beneficiaries
Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B and one of the following Medicaid Programs:
• Full Medicaid; or
• Special Need Plans, which include the following four programs:
○ Qualified Medicare Beneficiary (QMB) Program;
○ Specified Low-Income Medicare Beneficiary (SLMB) Program;
○ Qualifying Individual (QI) Program; and
○ Qualified Disabled Working Individual (QDWI) Program.
Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare-covered services are paid first by Medicare because Medicaid is always
the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover
Its coverage either categorically or throught optional coverage groups based on medically need status. Special income levels for institutionalized individuals or home and community based waivers
Medicaid pays for part A and part B premiums and cost sharing for Medicare providers to the extent consistent with Medicaid state plan
Medicaid pays for part A AND Part B premiums, deductibles, coinsurance and copayments for Medicare services furnished by Medicare providers to the extent consisten with Medicaid state plan
• Medicaid pays for Part B premiums
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).
We could only bill patient if they SLMB plan.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
Coverage Indications, Limitations, and/or Medical Necessity This LCD describes conditions under which the coverage of nail avulsion/ex...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, ...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...