02/26/2018

Collecting Copays for Patients With Medicare Advantage Plans and Medicaid

I have been told by a Medicare Advantage Plan that even if a patient has Medicaid but is NOT a QMB (Qualified Medicare Beneficiary) that not collecting the copay from the patient is a violation of their policies.....this is all so confusing- is that true?

A provider would only be in violation of a contractual agreement with the Medicare Advantage plan if the copay was discounted with no attempt to submit the balance to Medicaid as the secondary. If a patient has active Medicaid coverage as secondary on the date of an encounter that covers medical services, under no circumstances should the copay be billed to the patient (regardless if they are a QMB, MQMB, etc). The balance must be submitted to Medicaid as the secondary for processing. Depending on the amount of the copay and the procedure code billed to Medicaid, a portion of the balance may be paid, or may have to be written off as a contractual adjustment per Medicaid. As long as the balance is submitted to the secondary processing, there is no problem.