Mont. Admin. R. 37.83.825 - QUALIFIED MEDICARE BENEFICIARIES, PAYMENTS TO PROVIDERS
(1) Payments for services provided to
medicaid qualified medicare beneficiaries may only be made to a provider. A
provider in order to receive payments must be enrolled in the medicaid program.
(a) Medicaid payment will be made to the
provider even when the provider for medicare purposes has not accepted
assignment.
(2) Payment
in full, except as otherwise provided in (2) (a) below, for services provided
to medicaid qualified medicare beneficiaries, is the medicaid payment as
determined under ARM
37.83.811,
37.83.812 and
37.85.406 plus the qualified
medicare beneficiary's copayment as provided for in ARM
37.83.826. A provider may not
collect any amount from the person which is in excess of payment in full even
if that payment is less than the medicare insurance deductibles and
coinsurance. Where a person is eligible for medicaid under both medicaid
qualified medicare beneficiary and another medicaid category, a provider must
accept the medicaid payment as payment in full.
(a) Where a provider does not accept medicare
assignment and the person receiving medicaid services is medicaid eligible only
as a qualified medicare beneficiary, the provider may bill the person for that
portion of the service cost that is the difference between medicare's allowable
rate and the provider's charge. A provider who does not accept medicare
assignment must inform a person receiving services that this portion may be
billed to the person.
(3) Subject to the requirements of this rule,
the Montana medicaid program pays the lowest of the following for qualified
medicare beneficiary services:
(a) the
provider's usual and customary charge for the service; or
(b) the appropriate medicaid allowed amount
as provided in ARM
37.85.406(18).
Notes
Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-6-101 and 53-6-131, MCA;
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