Change to Medicaid Reimbursement of Medicare Part C Co-payment and Co-insurance Liabilities

Effective April 1, 2016, an amendment to New York State Social Services Law changes Medicaid reimbursement of Medicare Part C (Medicare Advantage or Medicare managed care) co-payment and/or co-insurance liabilities for services provided to dually eligible Medicaid members. Dually eligible members are those individuals having both Medicare and Medicaid coverage. Presently the Medicaid program pays the full co-payment or co-insurance amounts for Medicare Part C claims. Retro-actively to April 1, 2016, Medicaid will reimburse at the rate of eighty-five percent (85%) of the Medicare Part C co-payment or co-insurance amount. Paid claims will be adjusted automatically to reflect the new cost-sharing limits. This change will affect institutional claims and professional claims. A provider of a Medicare Part C benefit cannot seek to recover any co-payment, or coinsurance amount from Medicare/Medicaid dually eligible individuals. The provider is required to accept the Medicare Part C health plan payment and any Medicaid payment as payment in full for the service. The member may not be billed for any Medicare Part C co-payment/co-insurance amount that is not reimbursed by Medicaid.