360-7.7 Payments of deductibles and coinsurance under Title XVIII of the Social
Security Act (Medicare).
(a) The MA program will pay on behalf of qualified Medicare
beneficiaries, as defined in subdivision (g) of this section, the full amount of any
deductible and coinsurance costs incurred under Part A or B of Title XVIII of the Social
Security Act (Medicare).
(1) The MA program will pay the full amount of
such deductible and coinsurance costs for care, services or supplies included in the MA
program and for care, services or supplies that are not included in the MA program.
(2) The MA program will pay the full amount of
such deductible and coinsurance costs for qualified Medicare beneficiaries who are
otherwise eligible for MA and for qualified Medicare beneficiaries who are not otherwise
eligible for MA.
(b) The MA program will pay on behalf of MA recipients who are also
eligible for benefits under Part A or B of Title XVIII (Medicare), but who are not
qualified Medicare beneficiaries, the full amount of any deductible or coinsurance costs
incurred under such part provided that the costs were incurred for care, services and
supplies included in the MA program.
(c) Before the MA program will pay any Medicare Part B deductible or
coinsurance liability, the MA recipient or qualified Medicare benficiary must assign to
the provider any Part B benefit payment to which he or she is entitled. The provider of a
Medicare Part B benefit must accept assignment from such recipient or beneficiary of his
or her right to receive the Medicare Part B payment.
(d) A provider of Medicare Part B benefits must not seek to recover any
Medicare Part B deductible or coinsurance amounts from an MA recipient or qualified
Medicare beneficiary.
(e) To be paid for transportation services that are not paid through
the Medicaid Management Information System, a provider must submit to the social services
district bills for deductible and coinsurance amounts and the explanations of benefits
form issued by the Medicare carrier. A provider does not have to submit the explanation of
benefits form to a district which can obtain this information from the Medicare Part B
fiscal agent's computer files. A district must apply Medicare Part B benefits before
making MA payments for claims.
(f) Reimbursement is not available under the MA program for services or
supplies furnished pursuant to Title XVIII of the Social Security Act (Medicare) if:
(1) the provisions of such Title or the
regulations promulgated to implement such Title preclude a provider of such services or
supplies from charging a medicare beneficiary for the cost of the supplies or services
provided; or
(2) the provider agrees, under the terms of a
medicare provider agreement, not to charge an individual for the cost of services or
supplies.
(g) Qualified Medicare beneficiaries.
(1) As used in this section and section 360-7.8
of this Subpart, the term qualified Medicare beneficiary means a person:
(a) who is entitled to
hospital insurance benefits under Medicare Part A;
(b) whose income does
not exceed 100 percent of the poverty line, as defined in section 360-1.4 of this Part,
applicable to a family of the size involved;
(c) whose resources do
not exceed twice the maximum amount of resources that the person may have to be eligible
for Supplemental Security Income benefits; and
(d) who meets the
non-financial eligibility requirements contained in Subpart 360-3 of this Part.
(h) Qualified Disabled and Working Individuals. As used in this section
and section 360-7.8 of this subpart, the term qualified disabled and working individual
means a person who is not otherwise eligible for medical assistance and:
(1) who is entitled to hospital insurance
benefits under Section 1818A of Part A of Title XVIII of the Social Security Act;
(2) whose income does not exceed 200 percent of
the official federal poverty line applicable to the person's family size; and
(3) whose resources do not exceed twice the
maximum amount of resources that an individual or a couple, in the case of a married
individual, may have and obtain federal supplemental security income benefits under Title
XVI of the federal Social Security Act, as determined for purposes of that program.
(i) Specified low income Medicare beneficiaries. As used in this
section and section 360-7.8 of this Subpart, the term specified low income Medicare
beneficiary means a person:
(1) who would be a qualified Mediare
beneficiary as defined in 360- 7.7(g) of this Subpart except that the person's income
exceeds the regulatory income requirements; and
(2) whose income is greater than 100 percent of
the official federal poverty line applicable to the person's family size but in calendar
years 1993 and 1994, is less than 110 percent of such poverty line and, in calendar years
beginning in 1995, is less than 120 percent of such poverty line.