Medicaid Reimbursement of Medicare Cost Sharing

EMedNY has issued a reminder to Medicaid providers regarding a provision enacted in the 2016-17 State Budget that caps Medicaid co-insurance and co-payments, commonly referred to as cross-over payments, for services provided to individuals eligible for both Medicare and Medicaid who are enrolled in Medicare managed care (i.e., Medicare Part C or Medicare Advantage).  

Currently, Medicaid pays the full co-payment or co-insurance amount for these individuals. When implemented, this provision will reduce these Medicaid payments to 85 percent of the co-insurance or co-payment amounts that would be borne by a Medicare beneficiary not eligible for Medicaid.  This includes the full scope of services offered by a Medicare Part C plan (including services covered by Part A and Part B under traditional Medicare), with the exception of ambulance and psychologist services.  

The Department of Health (DOH) is in the process of making the required systems changes to implement this new provision. Once complete, paid claims retroactive to the effective date of the provision will be adjusted automatically to reflect the new cost-sharing limit. DOH indicates that providers will be notified throught a Medicaid Update article prior to the adjustment being made. (Although the eMedNY alert lists the effective date of this change as April 1, 2016, the State Budget states the effective date as July 1, 2016. We have pointed this out to DOH and are seeking clarification from them.)      

Please note that this change impacts Medicare beneficiaries enrolled in Medicare managed care; cross-over payment limits for dually eligible individuals covered by fee-for-service Medicare Part B were enacted the previous year.

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Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841