04/05/2016

Medicare Dual Eligible Changes – An Explanation

We have received multiple questions regarding the recent changes to the Medicare/Medicaid Dual Eligible program. (See related articles under Latest News on the website:  12/21/2015 New York DOH Targets Dual-Eligible Program Reform and 12/03/2015 Reminder to All Medicare Part B Providers)

For dual enrolled patients in Medicare Advantage plans, the cost sharing is paid under the Medicaid program.  A physician cannot collect from the member.  Instead, the physician must collect from the state. CMS specifically requires Medicare Advantage plans to include language in their provider contracts that states the following –

“For all enrollees eligible for both Medicare and Medicaid, provider may not hold the enrollee liable for Medicare Part A and B cost sharing when the State is responsible for paying such amounts.  Provider may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under Medicaid if the individual were not enrolled in such a plan.  Provider will: (1) accept the Medicare Part A plan payment as payment in full, or (2) bill the appropriate State source.”

There are significant penalties under Medicare for trying to collect cost sharing in excess of the allowed amount from dual eligibles. If the plan is a Medicare Advantage Dual Eligible Special Needs Plan, CMS directs the plan to only reflect the Medicare coverage in the evidence of coverage.  Thus the cost sharing would appear very high but generally is covered by the state.

The only place you would see low cost sharing for a dual eligible plans would be organizations participating in the financial integration demo, which aren’t technically Medicare Advantage plans, and in NY are called “Fully Integrated Duals Advantage” (FIDA).  For those organizations, in addition to receiving Medicare payment from the federal government, the state pays the plan for the Medicaid amounts, so the cost sharing is very low (or non-existent) because the Medicare and Medicaid payments are integrated.