Denial of Medicaid to Dual Eligibles Not Enrolled in Medicare Part B

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Denial of Medicaid to Dual Eligibles Not
Enrolled in Medicare Part B

• (Issue alert dated 7/15/09 at http//www.mplp.org/
  )

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Dual Eligibles

• Medicaid
• Low income ( assets) before or after
  consideration of medical expenses
• Covered group
• Medicare
• Age gt 65
• Receiving Social Security disability gt 2 years

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Medicare Parts A B

• Part A hospitalization usually automatic, no
  premium
• Part B medical care outside of hospital
• 96.40 per month premium
• Higher premiums for late sign up
• Medicaid pays for full Medicaid beneficiaries
• Medicare Savings Programs (BEM 165) may pay
  premiums
• Limited Medicaid benefit QMB, SLMB, ALMB
• Up to 135 of federal poverty level (1219
  single, 1640 couple in 2009)

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• Medicaid recipients cannot be denied Medicaid
  for failure to enroll in Part B (PEM/BEM 257)
• BUT

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• Michigan Medicaid agency will not pay for
  services that are covered by Part B if the
  Medicaid recipient is a dual eligible, even if
  the person is NOT enrolled in Part B
• (PEM 257 and Medicaid Provider Manual
  Coordination of Benefits p.9)

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• Michigan Medicaid agency states that providers
  may bill a Medicaid beneficiary for services if
  he or she refuses Medicare Part A or B.
• (Medicaid Provider Manual Beneficiary Billing
  (General Information for Providers p. 17))

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3 Problems
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1.

• Medicaid must provide the same amount, duration
  and scope of medical services for all people
  within a Medicaid eligibility group (such as the
  group for medically need persons with
  disabilities). 42 USC 1396a(a)(10)(C).
• Therefore, Michigan Medicaid cannot provide
  Medicaid coverage for Part B covered services to
  (a) non-duals (those not eligible for
  Medicare) and to (b) duals who are enrolled in
  Medicare Part B, but deny Medicaid coverage for
  Part B services to duals who did not enroll in
  Part B.

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2.

• Medical providers who accept Medicaid must accept
  Medicaid payment as payment in full (except
  Medicaid-approved co-pays and deductible
  (spenddown)). Exception provider informs
  recipient up front and recipient elects to
  receive the service on a private pay basis. 42
  USC 1396a(a)(25)(C), 42 CFR 447.15, MCLA
  400.111b.
• Therefore, Michigan cannot authorize providers to
  bill for services that Medicaid will not pay
  because they individual had not enrolled in Part
  B.

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3.

• Medicaid must provide notice and an opportunity
  for a hearing to individuals whose claims for
  Medicaid are denied. 42 USC 1396a(a)(3), 42
  CFR 431.206-.211 and 435.919, and the due process
  clause of the Fourteenth Amendment.
• Therefore, recipients should get notice of the
  denial, the reasons, and their hearing rights
  when a Medicaid claim is denied because they did
  not enroll in Part B.

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Contact CCJ for more information or if you have
clients with this problem989 755 3120