Medicaid 20% Payment Policy Change

Due to new policy changes Medicaid will no longer pay the full 20 percent of the Part B coinsurance after Medicare pays its 80%. Instead, the total Medicare / Medicaid payment will not exceed the amount that Medicaid would have paid for a Medicaid-only patient. If the Medicare payment is greater than the Medicaid fee, Medicaid will make no additional payment. This revised reimbursement methodology was thought to be overturned or not in affect due to Medicaid paying for the 20% after the July deadline but in recent weeks we are seeing Medicaid request refunds for those payments and they are not paying current claims. Since the Medicaid payment system is not necessarily up to date it causes confusion on predicting what’s going to happen. Please note:

The Medicare and Medicaid payment (if any) must be accepted as payment in full. Per State regulation 18 NYCRR Section 360- 7.7, a provider of a Medicare Part B benefit cannot seek to recover any Medicare Part B deductible or coinsurance amounts from Medicare/Medicaid Dually Eligible Individuals.

There are some exclusions to this rule that are still very vague such as chemotherapy, psychologist and other entities such as Article XX clinics. Again we will be keeping a close eye and notifying as we follow legislation and claim processing information.

Medicaid Update Link


Bert Lurch