Medicare Compliance & Reimbursement

Good news:  Your state may cover copays, even for non-Medicaid patients.

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 Barbara Cobuzzi with CRN Healthcare Solutions in Tinton Falls, NJ. "So now it is a state by state issue," explains Cobuzzi.

The Medicare Modernization Act expanded programs for Medicare/Medicaid dual eligibles. There are three programs, according to Kim Glaun, senior policy counsel with the Medicare Rights Center in Baltimore:
 
· The Qualified Medicare Beneficiary (QMB) program pays premiums, copays and deductibles for Medicare Part A and B, for patients whose income is below the poverty level.

· The Specified Low-Income Medicare Beneficiary (SLMB) program only 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: Because many state Medicaid programs only cover people with incomes up to 75 percent of the poverty line, your patients may qualify for the QMB program even if they don't qualify for Medicaid, Glaun notes.

The problem: Even if your patients qualify for the QMB program, the state may not pay their copayments, Glaun warns. 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 the Medicare Payments Advisory Commission, roughly one-third of states currently don't pay for copayments for QMB patients.

In some cases, the state may set the Medicaid reimbursement at 90 percent of the Medicare rate--which would mean that you would at least be able to collect half the copayment from your state Medicaid program, Glaun says. Some states make it easy for you to collect copayments, while with others it's a hassle, she notes.

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