Paragraphs (A)(7) to (F)(4) of this rule do not apply to
pharmacy services covered under the medicare part D program. Pharmacy services
covered under the medicare part D program should be billed in accordance with
rule 5101:3-9-06
5160-9-06 of the Administrative Code.
(A) Definitions.
(1) "Medicare" is a federally financed
program of hospital insurance (part A) and supplemental medical insurance (also
called SMI and/or part B) for aged and
disabled persons.
(2) "Medicare
Benefits" means the health care services available to
the consumer
an
individual through the medicare program where payment for the services
are
is either
completely the obligation of the medicare program or in part the obligation of
the medicare program with the remaining payment
(cost sharing) obligations belonging to the
consumer
individual, some other third party payer
,
and/or
medicaid.
(3) "
Original
Traditional
Medicare
(also known as traditional
medicare)" is a health plan that pays for medicare benefits provided
to
beneficiaries
individuals on a fee-for-service basis.
(4) "Medicare Advantage Plan (also known as
medicare part C plan)" is a managed care delivery system that includes coverage
for both hospital insurance and SMI, but the delivery of health care services
are contracted to and provided by an approved medicare managed care plan,
preferred provider organization, private fee-for-service plans
, or medicare specialty plans.
(5) "Medicare Cost Sharing"
for the purpose of this rule means the portion of
a medicare crossover claim paid by medicaid.
(6) "Dual Eligibles or Dually Eligible
Consumers
Individuals" are individuals who are entitled to
medicare hospital insurance and
/or SMI and
are eligible for medicaid to pay some form of medicare cost sharing. The
following is a list of dual eligibles
or dually
eligible individuals that qualify to have medicaid pay all or part of the
cost sharing portion of a paid medicare claim:
(a) "Qualified Medicare Beneficiaries without
Other Medicaid (QMB Only)" are individuals entitled to medicare hospital
insurance, have income of one hundred per cent of the federal poverty level
(FPL) or less and resources that do not exceed
the
maximum amount of resources allowed under section 1905(p)(1) of the Social
Security Act (as in effect on October 1, 2018), as adjusted annually according
to the change in the consumer price index for urban areas (CPI-U)
twice the limit for supplemental security income (SSI)
eligibility, and are not otherwise eligible for full medicaid
benefits.
(b) "QMBs with Full
Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance,
have incomes of one hundred per cent FPL or less and resources that do not
exceed
the maximum amount of resources allowed under
section 1905(p)(1) of the Social Security Act (as in effect on October 1,
2018), as adjusted annually according to the change in the consumer price index
for urban areas (CPI-U)
twice the limit for SSI
eligibility, and are eligible for full medicaid benefits.
(c) "Specified Low-Income Medicare
Beneficiaries with Full Medicaid (SLMB Plus) " are individuals entitled to
medicare hospital insurance, have income of greater than one hundred per cent
FPL, but less than one hundred twenty per cent FPL and resources that do not
in exceed twice the limit for SSI
eligibility, and are eligible for full medicaid benefits.
(d) "Medicaid Only Dual Eligibles (for
example Non QMB)" are individuals entitled to medicare hospital insurance
and/or SMI and are eligible for full
medicaid benefits. They are not eligible for medicaid in any of the other dual
eligible categories (for example QMB). Typically,
these individuals need to spend down to qualify for medicaid or fall into a
medicaid eligibility poverty group that exceeds the limits of other dual
eligible categories.
(7) "Medicare Crossover Claim" means any
claim that has been submitted to the Ohio department of
job and family services (ODJFS)
medicaid (ODM) for medicare cost sharing payments
after the claim has been adjudicated and paid by the medicare central
processor, medicare carrier/intermediary or the medicare managed care plan
and the medicare central processor or medicare
carrier/intermediary has determined the deductible, coinsurance and/or
co-payment amounts. Claims denied by the medicare carrier/intermediary
or the medicare managed care plan are not considered medicare crossover claims.
See paragraphs (E) and (F) of this rule for policy on services denied or not
covered by medicare.
(a) "Automatic Crossover
Claim" is a medicare claim submitted to
ODJFS
ODM via the
automatic medicare crossover process described in paragraph (B)(2)(a) of this
rule.
(b) "Provider-Submitted
Crossover Claim" means a medicare crossover claim submitted to
ODJFS
ODM as
described in paragraph (B)(2)(b) of this rule.
(B) Medicare crossover process.
(1)
ODJFS will no
longer accept the JFS 06780 "Medicaid Claim Billing" form (rev.10/2001) for
processing and payment of medicare crossover claims. Medicare
crossover claims must meet the claim submission guidelines in accordance with
rule
5101:3-1-19
5160-1-19 of the Administrative Code.
(2) The medicare program determines the
portion of medicare cost sharing, if any, due to the provider based on
medicare's business rules and submits the claim for payment to
ODJFS
ODM
using the automatic medicare crossover process.
(a) The "Automatic Medicare Crossover
Process" is the coordination of benefit (COB) process whereby the provider
bills medicare for services provided to
the patient
who meets the criteria described in paragraphs (A)(6)(a) to (A)(6)(d) of this
rule or is a dual eligible
or a dually
eligible individual described in paragraph (A)(6) of this rule. Medicare
adjudicates the claim, pays the provider and electronically submits the claim
to
ODJFS
ODM
for the medicare cost sharing
amounts
determination. Then,
when
appropriate, the provider is paid by medicaid within ninety days from the
date of payment by medicare.
(b)
When the automatic medicare crossover process does not work (i.e., the provider
has received payment by medicare, has not received a payment from medicaid for
the medicare cost sharing portion and at least ninety days has elapsed from the
date of the receipt of the medicare payment), the provider
may
must
submit a medicare crossover claim directly to
ODJFS
ODM. This is
considered the "Provider-Submitted Crossover Claim Process."
(3) For a provider to receive
reimbursement through the automatic medicare crossover process, all of the
following criteria must be met:
(a) The
provider must be recognized as both a medicare and medicaid provider;
(b) The provider must accept medicare
assignment; and
(c) The
consumer
individual must be receiving health care benefits
under the
original
traditional medicare part A and part B program (i.e.,
the
consumer
individual is not enrolled in a medicare managed care
plan). At this time
ODJFS
ODM does not have payer-to-payer COB arrangements with
medicare managed care plans.
(4) For medicare crossover claims, the total
sum of the payments made by
ODJFS
ODM, medicare and
/or all other third party payers is considered
payment in full and no additional payment may be requested from the
consumer
individual with the exception of medicare co-payments
as specified in paragraph (E)(5) of this rule. This is true whether or not the
provider normally accepts assignment under medicare.
(a) When the provider's total reimbursement
from medicare and all other third party payers equals or exceeds the medicare
approved
(allowed/covered) amount, no
additional payment will be made by
ODJFS
ODM.
(b) If payment (other than the cost sharing
amounts) is inadvertently received from both medicare and medicaid for the same
service, the
provider must notify the
ODJFS
ODM
claims adjustment unit
must be notified in
accordance with the provisions set forth in rule
5101:3-1-19
5160-1-19
of the Administrative Code.
(5) Provider submitted crossover claims must
be submitted timely in accordance with rule
5101:3-1-19
5160-1-19
of the Administrative Code.
(6)
Crossover claims are not subject to medicaid co-payments in accordance with
rule
5101:3-1-09
5160-1-09 of the Administrative Code.
(C) When the
medicaid consumer
individual receiving medicaid is covered by other
third party payers, in addition to medicare, medicaid is the payer of last
resort. Whether or not medicare is the primary payer, providers must bill all
other third party payers prior to submitting a crossover claim to
ODJFS
ODM in
accordance with rule
5101:3-1-08
5160-1-08 of the Administrative Code.
(D)
ODJFS
ODM will not pay
for services denied by medicare for lack of medical necessity, but may pay
claims denied for reasons other
then
than lack of medical necessity in accordance with
paragraph (F) of this rule as long as the services are covered under the
medicaid program.
ODJFS
ODM will not pay for any service payable by, but not
billed to, medicare.
(E)
Reimbursement for medicare cost sharing on medicare crossover claims.
Reimbursement for medicare crossover claims is limited to the
dual eligibles or dually eligible individuals
listed in paragraph (A)(6) of this rule.
(1) The medicaid maximum reimbursement for
the medicare cost sharing of hospital inpatient, outpatient or emergency room
services is set forth in rule
5101:3-2-25
5160-2-25 of the Administrative Code for
consumers
individuals that elected to receive medicare benefits
under
original
traditional medicare.
(2) The medicaid maximum reimbursement for
the medicare cost sharing of nursing facility services included in the nursing
facility per diem is set forth in Chapter
5101:3-3
5160-3 of
the Administrative Code for
consumers
individuals that elected to receive medicare benefits
under
original
traditional medicare.
(3) The medicaid maximum reimbursement for
the medicare cost sharing of all other part B services not included in
paragraph (E)(1) or
paragraph (E)(2) of this rule
is set forth in rule
5101:3-1- 05.3
5160-1- 05.3 of the Administrative Code for
consumers
individuals that elected to receive medicare benefits
under
original
traditional medicare.
(4) The medicaid maximum reimbursement for
the medicare cost sharing of all advantage plan (part C) services is set forth
in rule
5101:3-1- 05.1
5160-1- 05.1 of the Administrative Code for
consumers
individuals that elected to receive medicare benefits
under a medicare advantage plan.
(5) Cost sharing for medicare part D services
is not reimbursable by
ODJFS
ODM in accordance with rule
5101:3-9-06
5160-9-06
of the Administrative Code.
Dually
Dual eligibles or dually eligible
consumers
individuals may be required to pay medicare
co-payments for prescription drugs that are covered by medicare part D.
(F) Services that are
not covered by medicare must be submitted to
ODJFS
ODM as a regular
medicaid claim and should never be submitted as a medicare crossover claim.
With the exception of long term care nursing facilities, when
the service is denied by medicare, and is also denied by medicaid with an error
message indicating that the service is covered under medicare and the provider
has documentation to support the service is not covered under medicare, the
provider must do all of the following when requesting payment consideration
from ODJFS
ODM:
(1)
Submit the appropriate claim in accordance with rule
5101:3-1-19
5160-1-19
of the Administrative Code;
(2)
Attach the summary notice of medicare benefits that shows the denied medicare
services, and the denial reason code with the denial reason code explanation
from the medicare summary of benefits, the provider is requesting
ODJFS
ODM to
consider for payment;
(3) Attach a
completed "
JFS
ODM 06653 Medical Claim Review Request Form (rev.
05/2010
7/2014
)"
with supporting documentation; and
(4) Submit all forms together to the address
indicated on the
JFS
instruction page accompanying the ODM 06653
form.
(G) Long term care
nursing facility providers must submit the appropriate claim in accordance with
Chapter
5101:3-3
5160-3 of the Administrative Code.
Notes
Ohio Admin. Code
5160-1-05
Effective:
9/16/2019
Five Year Review (FYR) Dates:
6/14/2019 and
09/16/2024
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5164.01,
5165.47,
5162.03,
5164.02
Prior
Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 04/01/1979, 10/01/1984,
10/01/1987, 01/09/1989 (Emer.), 04/10/1989, 05/01/1990 (Emer.), 07/01/1990,
05/30/2002, 12/18/2006, 07/31/2009 (Emer.), 10/29/2009,
08/02/2011