Update on Dually Eligible Beneficiaries

Published in Billing, Reimbursement, Audits and Compliance on January 09, 2019

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.

See the announcement from CMS.


comments powered by Disqus

From Our Experts

Member Q&A From The van Halem Group: New Order Requirement and Member Q&A From The van Halem Group: New Order Requirement and "Master List" I'm curious about this new order requirement. I see that Medicare updated the notice on 2/12/20, and I'm curious about the “Master List” of items that still needs a WOPD. I'm wondering if PAP equipment and supplies fall under the SWO or the WOPD. Can you help me understand? The Cost of Compliance – An Impassioned Plea to be Proactive thumbnail The Cost of Compliance – An Impassioned Plea to be Proactive Last year, The van Halem Group was engaged by several DME providers that were subject to a 6-year OIG lookback audit. Sadly, for companies that did not have a process in place for proactive chart audits, the 6-year look back resulted in a very expensive lesson. Lookback audits are here to stay, and it's never been more important for providers to have a comprehensive proactive compliance program, and this is one way that The van Halem Group can assist members. OIG to Review PMD Repairs and PAP Supplies thumbnail OIG to Review PMD Repairs and PAP Supplies The Office of Inspector General (OIG) has updated its work plan to include new reviews for PAP replacement supplies and power mobility device repairs. In a recent article from HME News, Medicare paid approximately $945.8 million for replacement supplies in 2017 and 2018, but OIG has previously found that most claims did not comply with Medicare requirements and that DME suppliers often did not have the documentation required to support the need for replacement supplies. Are Inhalation Drugs the Next OIG Six Year Lookback Audit? thumbnail Are Inhalation Drugs the Next OIG Six Year Lookback Audit? Since 2010, the CMS's Comprehensive Error Rate Testing (CERT) program has identified nebulizers and related drugs (i.e., inhalation drugs) among the top 20 supplies with the highest improper Medicare payments. Based on prior reviews, the Office of Inspector General (OIG) conducted a nationwide review to determine if the suppliers included in the review complied with Medicare requirements when billing for inhalation drugs. Ronda Says: Are You Ready for Oct. 21? Group II Support Surfaces Enter Prior Authorization Program for All States thumbnail Ronda Says: Are You Ready for Oct. 21? Group II Support Surfaces Enter Prior Authorization Program for All States CMS announced in Dec. 30, 2015 a finalized rule creating a program called Condition of Payment Prior Authorization Program for Certain DMEPOS items. The Value and Importance of Bid Calculators for Round 2021 Competitive Bidding thumbnail The Value and Importance of Bid Calculators for Round 2021 Competitive Bidding If someone would have told me a year ago that for the next round of Competitive Bidding (CB) a Durable Medical Equipment (DME) supplier could lose $100,000, $250,000, $500,000, or even $1,000,000 or more in revenue by bidding rates that were equal to the rates that are in place today, I would have said you were crazy. How Competitive Bidding Will Impact Reimbursement Rates for Non-Bid Areas thumbnail How Competitive Bidding Will Impact Reimbursement Rates for Non-Bid Areas So, you think that because you do not serve or operate within a competitive bid area (CBA), that Round 2021 of the Competitive Bidding (CB) program for DMEPOS products and services doesn't matter to you or doesn't impact you and your business? Think again! Zip Code Designation Changes – Affecting Reimbursement Rates thumbnail Zip Code Designation Changes – Affecting Reimbursement Rates   Between the first and second quarter of 2019, a to...