NCTracks
Changes to Ongoing Payment of QMB Crossover and Secondary Claims on Nov 1
As noted in the July 15, 2015, announcement (see link below), the N.C. Division of Medical Assistance (DMA) conducted a comprehensive review of changes made to its processing of Medicare crossover and secondary claims for services rendered to Qualified Medicare Beneficiaries (QMBs). It was determined that the changes implemented on March 1, 2015, were not aligned with the federal Centers for Medicare and Medicaid Services’ (CMS) evolving guidance to state Medicaid plans.
This change is applicable to beneficiaries with the following Category of Eligibility codes: MQBQN, MAAQN, MAAQY, MABQN, MABQY, MADQN, MADQY, SAAQN, SAAQY, SADQN, and SADQY.
To align the processing of Medicare crossover and secondary claims for services rendered to QMB recipients with CMS guidance, DMA has been taking a series of steps. The next step in this process is to implement the ongoing payment methodology for QMB crossover and secondary claims.
“Lesser of” Logic
Beginning November 1, 2015, the “lesser of” logic will be applied to services covered by both Medicare and Medicaid that are rendered to QMB recipients. Specifically, payment for Medicare-covered services that are also covered in the Medicaid state plan will be paid at the lesser of the Medicare cost-share (which is the sum of co-insurance, deductible and co-pay) or the difference between the amount paid by Medicare and the Medicaid state plan rate (if any). Refer to the Medicare Crossover Update dated October 7, 2013, for additional information.
For services not covered under the North Carolina Medicaid plan, DMA will pay the Medicare cost share amount.
This applies to crossovers as well as secondary filed claims (Part C) for Q class recipients. This methodology results in the provider receiving the Medicare or Medicaid allowable and the QMB recipient not being responsible for any additional monies for services covered by Medicaid and/or Medicare.
The final step to be taken in this process is to address the previously paid QMB crossover and secondary claims for services not covered under the North Carolina Medicaid plan, where the provider should have received the Medicare cost share amount. The date for reprocessing of these claims has not yet been determined. More information will be posted as soon as it is available.