RETROACTIVE ELIGIBILITY
Providers should be aware that, since bills have to be incurred before the deductible amount is met, there is always a period of retroactive eligibility. This may be several days or up to a period of three months from the current month. In this situation, the local MDHHS office may apply these old bills to the past three months or may prospectively apply them to the next several months, depending on the DOS and the date the bill was presented to the MDHHS worker.
It is the provider’s option to bill Medicaid if the beneficiary has paid the provider for services rendered. MDHHS encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service. If the provider decides to bill Medicaid, he must return all money the beneficiary paid over and above the amount identified as the beneficiary’s responsibility on the Medicaid deductible letter. If the beneficiary is accepted as a Medicaid beneficiary, he cannot be charged more than indicated on the letter from the local MDHHS office (plus applicable copayment amounts).
Retroactive Medicare Entitlement Involving State Medicaid Agencies
The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:
(a) At the time the service was furnished the beneficiary was not entitled to Medicare.
(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.
(c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.
In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare. After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare. Finally, sometime after the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier. If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.
In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:
• documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;
• documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check the CWF database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement; see the example in section 70.7.2 above concerning the CWF for additional details regarding this contractor verification process); and,
• documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.
If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.
Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization
The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:
(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.
(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.
(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.
There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.
In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:
• prior enrollment of the beneficiary in an MA plan or PACE provider organization;
• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;
• the effective date of the disenrollment; and,
• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.
If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.
ELIGIBILITY
There are cases when beneficiaries have the medical need for Medicaid coverage but they have excess income. These beneficiaries are known as Medicaid deductible beneficiaries. Medicaid deductible means that the beneficiary must incur medical expenses each month equal to, or in excess of, an amount determined by the local MDHHS worker to qualify for Medicaid. Once the deductible amount has been incurred, the beneficiary becomes eligible for Medicaid benefits (Benefit Plan ID of MA). Providers must verify Medicaid coverage using the Benefit Plan ID(s) provided in the CHAMPS Eligibility Inquiry.
The process for a Medicaid deductible beneficiary to become Medicaid eligible is as follows:
** The beneficiary presents proof of any medical expenses incurred (e.g., insurance premiums, bills for prescriptions and/or office visits) to the MDHHS worker. Providers may estimate any other insurance or Medicare payment that may be applied to the incurred bill. If the exact charge is not immediately known, providers should estimate the charge on the incurred bill. This expedites the eligibility process.
** The local MDHHS worker reviews the medical bills incurred, and determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility.
** It is fraud to provide beneficiaries with a notice of a bill incurred if no service has been rendered.
** Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary’s responsibility.
** For the first date of eligibility, the MDHHS worker sends letters to those providers whose services are:
** Entirely the beneficiary’s responsibility.
** Partly the beneficiary’s responsibility and partly Medicaid’s responsibility.
** A letter is also sent to the beneficiary indicating which services are the beneficiary’s responsibilities for that first date of Medicaid eligibility.
** The beneficiary’s Benefit Plan ID is changed to MA or MA-ESO to indicate the Medicaid eligibility period. The provider must verify eligibility using the CHAMPS Eligibility Inquiry when the beneficiary becomes eligible. Once the deductible amount is incurred, eligibility is established through the end of the month.
Providers may bill Medicaid for any covered services rendered during that eligible period. Before billing, providers should verify that the Benefit Plan ID of MA or MA-ESO is on file for the DOS. This will assure that the claims will not be rejected for lack of eligibility.
