Here’s How You’ll Get Paid for Dual-Eligible Patients

The Texas Health and Human Services Commission has eliminated Medicare Part B coinsurance and deductible payments for patients dually-eligible for Medicare and Medicaid, if the payment would result in the state paying more than the Medicaid allowable.

The only exception to this policy applies to renal dialysis services, for which cost-sharing payments are reduced by 5 percent.

Here are some examples from TMA’s white paper on payment for patients dually-eligible for Medicare and Medicaid. They are for illustration only; Medicare payments vary by region of the state.

Example 1: Established dual-eligible patient has not met any of the Medicare deductible and is seen during a routine office visit. Physician bills Medicare CPT code 99213. Maximum Medicare allowable is $66.90 (rest of Texas). Medicare pays $0 because deductible has not been met. Medicaid will pay $33.27, the Medicaid allowable for this code.

Example 2: Established dual-eligible patient has met $100 of $140 Medicare 2012 deductible. Patient is seen in office for routine office visit. Physician bills Medicare CPT code 99213. Medicare pays $21.52, which is 80 percent of the allowable after deductible ($66.90-$40). Medicaid will pay $11.75 ($33.27-$21.52).

Example 3: Established dual-eligible patient visits physician office for routine visit; Medicare deductible has been met. Physician bills Medicare CPT code 99213. Medicare allowable is $66.90. Medicare pays $53.52, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. Medicaid allowable is $33.27, so no coinsurance will be paid.

Published Feb. 9, 2010


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