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Update on Dually Eligible Beneficiaries

Posted on in Government and Advocacy

by VGM Government Relations

Good news coming from the CMS front regarding Medicare and Medicaid dually eligible beneficiaries. There are many cases where suppliers have a patient who is both Medicare and Medicaid eligible, and the order is for an item that Medicare considers as non-covered under the DMEPOS benefit. However, the item is payable under the Medicaid benefit (e.g., incontinence supplies). Many states are required to follow their regulations that indicate a claim must be submitted to Medicare primary to receive the denial in order to submit the claim to Medicaid and be reimbursed by Medicaid.

CMS has recognized the issues with this process, and is “providing another strategy for states to better support timely access to DMEPOS.” CMS has updated the language stating, “We are providing guidance that states need NOT to obtain Medicare denial for DMEPOS that Medicare routinely denies as non-covered under Medicare DME benefit.”

The state Medicaid should develop a list of those items non-covered by Medicare to help streamline processes and timely beneficiary access for the dually eligible beneficiaries. The states are also supposed to encourage the Medicaid managed care organizations to adopt the same list of non-covered items under the Medicare DME benefit.

Click here to see the announcement from CMS.