Changes in Payment of Medicare Crossover Claims for QMB Cost Sharing

As described in the CMS Informational Bulletin, Payment of Medicare Cost Sharing for Qualified Medicare Beneficiaries (QMBs) dated June 7, 2013, Medicaid is legally obligated to reimburse providers for cost sharing that is due for a QMB according to the state's CMS-approved Medicare cost-sharing payment methodology. QMBs, or those Medicare recipients qualified under the Medicare Catastrophic Coverage Act of 1988, include recipients with the following Program Aid Categories with Q classification: MQBQ, MAAQ, MABQ, MADQ, SAAQ and SADQ. In addition, the NCTracks system must adjudicate and reimburse providers for QMB cost sharing "without regard to whether the costs incurred were for items and services for which medical assistance is otherwise available under the plan, i.e., not covered by NC Medicaid."

Beginning March 1, 2015, NCTracks will pay the entire Medicare cost sharing amount (deductible, coinsurance and copayment) on claim detail lines for dates of service (DOS) during the time when a recipient is identified as QMB. The “lesser of logic� to which most Medicare crossover claims are subject will no longer be applied to claims for QMB recipients. This includes Medicare crossover claims for services not covered by Medicaid and claim detail lines that were denied by Medicare during the time when a recipient is identified as QMB, as well as Medicare Part C claims.

This change affects claims subject to QMB cost sharing regardless of how they are submitted, both when they automatically crossover from Medicare and when the secondary claim is submitted directly to NCTracks by the provider.

Medicare crossover claims subject to QMB cost sharing that were processed by NCTracks prior to March 1, 2015, will be reprocessed to reimburse providers for the entire Medicare cost sharing amount. The schedule for claim reprocessing has not yet been determined. More information will be posted when it is available.

(This is an update to the announcement originally posted on February 24, 2015.)