Do Not Balance Bill Dual-Eligible Members

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Do Not Balance Bill Dual-Eligible Members


State regulation states that a health care professional or facility that provides Medicare Part A or Part B services cannot collect any deductible, coinsurance or copay amounts from Medicare/Medicaid dually-eligible individuals. (State Regulation 18 NYCRR Section 360-7.7)

Medicare and Medicaid payment, if any, must generally be accepted as payment in full.

If you provide health care services for EmblemHealth Medicare Advantage members that are dually-eligible, you must:

  • Bill the Managing Entity as primary payer.
  • Bill the state Medicaid plan as secondary payer.
  • Accept the Medicaid payment as payment in full.
  • Avoid collecting any cost-share from the member if he/she participates with their state Medicaid program.
  • Notify the member, prior to giving care, if you do not accept the state Medicaid as payment in full.

For more information:

Centers for Medicare & Medicaid Services (CMS) Download (PDF)