Revised Reimbursement Methodology for Services to Medicare/Medicaid Dually Eligible Individuals

Date Issued: 4/18/2016

Pursuant to 2015 changes to Social Services Law, the New York State Department of Health (DOH) has revised the Medicaid reimbursement methodology for claims containing Medicare Part B services, including certain drugs and supplies provided by pharmacies, for Medicare/Medicaid dually eligible individuals.

Effective January 1, 2016, Medicaid will no longer reimburse partial Medicare Part B coinsurance amounts when the Medicare payment exceeds the Medicaid fee or rate for that service. If the Medicare payment is greater than the Medicaid fee, no additional Medicaid payment will be made.

This change is retroactive to July 1, 2015. Previously paid claims will be adjusted automatically to reflect the new cost sharing limits. Providers will be notified prior to claim adjustments being made. Additional information on the effective date specific to pharmacy claims will be forthcoming.

There is no change to the current reimbursement methodology of Medicare Part B coinsurance for Ambulance providers, Psychologists or Federally Qualified Health Centers (FQHCs). These providers will continue to be paid the full Medicare Part B coinsurance amounts or up to the Medicaid rate as specified in State statute.

Reminder: Medicare and Medicaid payment (if any) must generally 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.

Please refer to the June 2015 Medicaid Update, July 2015 Medicaid Update and November 2015 Medicaid Update articles for more information.