State Implementing Copayment Reduction Provision

A provision in the enacted 2016-17 State Budget revised the Medicaid reimbursement methodology for claims containing Medicare Part C (Medicare Advantage or Medicare managed care) copayment and/or coinsurance liabilities. Instead of the full amount, Medicaid will reimburse only 85 percent of the full Medicare Part C copay or coinsurance amount. The Department of Health (DOH) is in the process of implementing this change now. This reduction is retroactive to July 1, 2016.

This provision impacts only Medicare managed care copayments and coinsurance. The change does not impact ambulance providers or psychologists, and there will be no change made to the reimbursement of the Medicare Part C deductible. Note that a similar reduction to coinsurance reimbursement for fee-for-service Medicare services was implemented previously.

DOH reminds providers that they are required to accept the Medicare Part C health plan payment and any Medicaid payment as payment in full for the service. The member may not be billed for any Medicare Part C copayment or coinsurance amount that is not reimbursed by Medicaid.

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