Eligibility and Entitlement for Persons with Medicare - JE Part B

Medicare coverage may be impacted by the following:

• End Stage Renal Disease (ESRD)
• Home Health Agency (HHA)
• Hospice
• Hospital
• Incarceration / Unlawfully Present
• Medicare Advantage Plan, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO)
• Medicare Secondary Payer (MSP)
• Qualified Medicare Beneficiary (QMB)
• Skilled Nursing Facility (SNF)
• Social Security Administration (SSA)
• Supplemental Insurance Coverage

End-Stage Renal Disease (ESRD)

When a patient elects to receive dialysis, the ESRD facility is responsible for services related to his/her dialysis. Providers may confirm if a service is related to the patient's stay by speaking with the ESRD facility. For services not related, providers may append modifier AY.

Home Health Agency (HHA)

When a beneficiary elects home health through a home health agency, the Medicare services received are subject to home health consolidated billing and include nursing and therapy services, routine and non-routine medical supplies, home health and medical social services are not paid separately by Medicare, but are paid to the home health agency.

Hospice

When a beneficiary elects a hospice, he/she waives all rights to Medicare payments for services related to the treatment of his/her terminal condition(s) or related condition equivalent to hospice care. Bill the attending physician services, who is not employed by hospice, with modifier GV. Bill services unrelated to terminal illness with modifier GW.

Hospital

When a beneficiary is considered inpatient in a hospital, Part B is responsible for the professional services. Providers submitting their professional services must bill using the appropriate POS matching the patient's status. For Pathology services, providers may submit the technical component to Part B only when the referring provider has received payment outside of the hospital for the same date of service (DOS).

Incarceration / Unlawfully Present

When a patient is a prisoner in custody and/or incarcerated, services are not covered by Medicare. Applicable federal, state or local authority may cover such claims. This includes situations such as home detention, supervised release, medical furlough, required residence in a mental health facility, or halfway house.

Medicare Advantage Plan, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO)

When a beneficiary elects an alternative to the traditional Fee for Service Medicare program, providers bill the alternative Medicare Advantage, HMO, or PPO plans.

Medicare Secondary Payer (MSP)

Patients may have insurance paying before Medicare and Medicare becomes secondary to a primary insurance.

Qualified Medicare Beneficiary (QMB)

Dual Eligible Medicare Medicaid Coverage

"Dual-eligible beneficiaries" are individuals enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A and/or Part B who also receive Medicaid benefits or assistance with Medicare premiums, or cost sharing through various programs. One program is the Qualified Medicare Beneficiary (QMB) Program which assists low-income beneficiaries with his/her Medicare premiums and cost sharing.

Certain requirements and restrictions apply when a beneficiary is dual eligible.

• Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries
• Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance, or copayments
• Medicare and Medicaid payments made for services rendered to a QMB are considered as payment in full
• Providers cannot charge QMB individuals even if patient's QMB benefit is provided by a different State
• Providers are encouraged to understand the processes required to request payment for Medicare cost-sharing amounts if owed by the State.
• Providers may need to complete a State Provider Registration Process and be entered into State payment system to bill the State
• All original Medicare and MA providers and suppliers–not only those accepting Medicaid–must abide by billing prohibitions

Skilled Nursing Facility (SNF)

When a beneficiary is considered inpatient in a SNF, services such as non-professional services, physical therapy, and ambulance transportation between two SNFs are subject to Skilled Nursing consolidated billing. If the service allows, provider may bill for the professional component to Part B.

Social Security Administration (SSA)

The SSA maintains a beneficiary's Medicare eligibility regarding the spelling of his/her name, date of birth, date of death, requests for new Medicare cards, effective/termination dates and/or related updates to Medicare information.

Supplemental Insurance Coverage

When a beneficiary has an insurance secondary to Medicare, those insurance agencies work with Medicare contractors to define the types of finalized claims (adjusted, initial, unprocessable) sent to them for processing. Each insurance company must provide accurate, timely files. When applicable, a provider's Medicare Remittance Advice (RA) will reflect the name of the supplemental insurance Medicare sent the claim-specific RA.