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Revised Reimbursement Methodology

Monday, July 6, 2015   (0 Comments)
Posted by: Bibiana Braun
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Revised Reimbursement Methodology for Practitioners Providing Services to Medicare/Medicaid Dually Eligible Individuals


Effective July 1, 2015 a change to New York State Social Services Law adjusts Medicare Part B coinsurances reimbursement methodology for practitioner claims: Medicaid presently pays practitioners the full Medicare Part B annual deductible and partial Medicare Part B coinsurance amounts (20 percent of the Part B coinsurance) for Medicaid covered services provided to Medicare/Medicaid dually eligible recipients. Pursuant to recent changes to Social Services Law, New York State Medicaid has revised the reimbursement methodology for practitioner claims effective July 1, 2015. Beginning July 1, 2015, Medicaid is no longer reimbursing partial Medicare Part B coinsurance amounts. The total Medicare/Medicaid payment to the provider will not exceed the amount that the provider would have received for a Medicaid-only patient. If the Medicare payment is greater than the Medicaid fee, no additional payment will be made.


Note: The Medicare and Medicaid payment (if any) must 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.

There is no change to the current reimbursement methodology of Medicare Part B coinsurance for the following: Ambulance providers; Psychologists; Article 16 clinics; Article 31 clinics; and Article 32 clinics. Medicaid will continue to reimburse these providers the full Medicare Part B coinsurance.

: If a patient is dually eligible, private practitioners must bill Medicare prior to billing Medicaid for the Part B co-insurance. Most claims are submitted to Medicare and are automatically crossed over to Medicaid for processing.





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