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FAQ Memo Helps Plans Train Providers on Cost-Sharing Hold Harmless Obligations

FAQ Memo Helps Plans Train Providers On Cost-Sharing Hold Harmless Obligations

A great Centers for Medicare and Medicaid Services (CMS) memo issued in July 2018 (link here) as well as other CMS literature (links here and here) help take the mystery out of plan and provider obligations to hold certain dual eligibles (those in both Medicare and Medicaid) harmless from certain cost-sharing. To this day, the rules are little known and Medicare beneficiaries regularly receive bills for cost-sharing they don’t owe and are balance billed.

Since 1997, federal law has prohibited providers from billing any Qualified Medicare Beneficiary (QMB) for unpaid Medicare deductibles and other cost-sharing. In practice, however, there are additional dual eligible categories sheltered from this type of cost-sharing.

The 1997 federal law covers:

  • QMB Only (who get just their Medicare deductibles and cost-sharing covered)
  • QMB Pluses (who also get full Medicaid benefits)

Other federal and state laws and rules shelter the following:

  • Full Benefit Dual Eligibles (FBDEs)
  • QMB Pluses (again, because they are FBDEs)
  • Supplemental Low-Income Medicare Beneficiary Pluses or SLMB Pluses (because they are temporarily FBDEs)

The only dual eligibles not sheltered are SLMB Onlys, Qualifying Individuals (QIs) and Qualified Disabled Working Individuals (QDWIs).

The federal hold harmless rules effectively mean the following:

  • The rules apply to both Medicare fee-for-service and Medicare Advantage (MA).
  • MA plans must include in provider contracts that these categories are not responsible for cost-sharing.
  • The prohibition on billing cost-sharing applies if the provider bills Medicare only or accepts both Medicare and Medicaid.
  • If enrolled, a provider can register with a state Medicaid agency as either a full Medicaid provider or a QMB Only provider in an effort to be compensated for some of the lost cost-sharing. However, federal law allows states to limit reimbursement for such cost-sharing to the Medicaid fee schedule. Because most Medicaid fee schedules are less than 80 percent of Medicare (the amount typically paid by the government), the provider usually receives nothing and must extinguish the unpaid amount.
  • This covers not just Dual Eligible Special Needs Plans but any dual eligibles enrolled in any MA plan.
  • Providers can collect any Medicaid copays and Part D copays (including LIS), costs of non-covered services and costs for non-network providers (not in the MA plan or not enrolled in Medicare FFS).

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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