Medicare Compliance & Reimbursement

Analyze these facts before writing off low income copays.

If your practice sees a lot of low income Medicare patients, you may be able to get a helping hand from your state.

The 1997 Balanced Budget Act gave the states the choice of whether or not to pay coinsurances and deductibles for Medicare-Medicaid patients, says Atlanta-based attorney Allison Larro. "States can make this decision on their own, so the rules vary depending on location."

The Medicare Modernization Act expanded programs for Medicare/Medicaid dual eligibles. There are three programs:

• The Qualified Medicare Beneficiary (QMB) program pays premiums, copays, and deductibles for Medicare Parts A and B, for patients with incomes at or below the poverty level.

• The Specified Low-Income Medicare Beneficiary (SLMB) program pays Part B premiums for patients with income between 100 and 120 percent of the poverty line.

• The Qualified Individual (QI) program also pays Part B premiums, for people with incomes between 120 and 135 percent of the poverty line.

Important: Since many state Medicaid programs set eligibility for full Medicaid at levels below the poverty line, your patients may qualify for the QMB program even if they don't qualify for Medicaid, says Paul Precht, director of policy and communications with the Medicare Rights Center in New York, N.Y.

The problem: Even if your patients qualify for the QMB program, the state may not pay their copayments. That's because some states say that their Medicaid rate is 80 percent of the Medicare rate. Therefore, the state argues that Medicare has already paid the full Medicaid amount, and the state isn't responsible for the extra 20 percent. According to Congressional Budget Office estimates, only 33 percent of eligible patients are enrolled in the QMB program, and only 13 percent are enrolled in SLMB. Some states make it easy for you to collect copayments, while with others it's a hassle.

Bottom line: Contact your state Medicaid agency to find out if it pays copayments for QMB patients, and what the procedure is.