Payment of Medicare Crossover Pharmacy Claims for QMB Recipients

Changes are forthcoming regarding the reimbursement of Medicare primary pharmacy claims for recipients with Medicaid eligibility classification of 'Q'. Beginning August 1, 2016, NCTracks will pay QMB and QMB+ (a.k.a. Q class) Medicare crossover pharmacy claims according to state policy: services covered by Medicaid are paid at Lesser of Logic, and services that are non-covered by Medicaid pay the full cost-share.

The determining factor regarding how the pharmacy crossover claims will be reimbursed is whether or not the NDC is covered by Medicaid on the date of service. If the NDC is covered by Medicaid on the date of service, the claim will process to pay according to the Lesser of Logic pricing methodology. If the NDC is not covered by Medicaid on the date of service, it will process to pay 100% of Medicare cost share.

Note: For recipients who are MQBQ, Medicaid payment can only be made for services that have been approved/allowed by Medicare. There is no coverage for straight Medicaid claims for MQBQ recipients.

Medicare crossover pharmacy claims paid between March 2, 2015, and July 31, 2016, will be reprocessed to apply the state policy. A further announcement will be published once the date for reprocessing has been finalized.