What is a Medicare-Medicaid plan?
Medicare-Medicaid Plans. Medicare is working with some states and health plans to offer demonstration plans for certain people who have both Medicare and Medicaid and make it easier for them to get the services they need. They’re called Medicare-Medicaid Plans. These plans include drug coverage and are only in certain states.
Does Medicare cover all of my health care costs?
If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan (Part C). If you have Medicare and full Medicaid, you'll get your Part D prescription drugs through Medicare.
How does Medicare work with Medicaid and Medicare?
If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan (Part C). If you have Medicare and full Medicaid, you'll get your Part D prescription drugs through Medicare.
Does Medicaid cover drugs that Medicare doesn’t?
Medicaid may still cover some drugs and other care that Medicare doesn’t cover. Who pays first—Medicaid or Medicare? Medicare pays first, and Medicaid pays second. Medicaid never pays first for services covered by Medicare. It only pays after Medicare, employer group health plans, and/or Medicare Supplement (Medigap) Insurance have paid.
What constitutes Medicare abuse?
What Is Medicare Abuse? Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.
What is the key law that makes it illegal to submit a falsified bill to Medicare?
False Claims Act [31 U.S.C. The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.
What is a reason that providers can be excluded from participation in Medicare or Medicaid?
Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, ...
Has responsibility for the Medicare and Medicaid programs?
Responsibility for administering the Medicare and Medicaid programs was entrusted to the Department of Health, Education, and Welfare—the forerunner of the current Department of Health and Human Services (DHHS).
What are examples of penalties that a healthcare provider could be subject to under the False Claims Act?
Health care providers and their employees can be subject to civil monetary penalties of $5,500 to $11,000 for EACH false claim submitted. They can be required to pay three times the amount of damages sustained by the United States government, and they may also be excluded from participation in Medicare and Medicaid.
What is considered a kickback in healthcare?
It's simple to define what kickbacks in health care are. If a physician or medical provider uses any payment or compensation to encourage a patient to come to their office, or to encourage another medical provider to refer patients to their office or facility, that is a kickback.
For which offenses would enforcement action be taken against a provider?
Criminal, civil or administrative legal actions relating to fraud and other alleged violations of law, initiated or investigated by OIG and its law enforcement partners.
What is the Medicare exclusion list?
According to the OIG, the List of Excluded Individuals/Entities (LEIE) “provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs.” Individuals and entities are ...
Why would someone be on the Sam exclusion list?
An exclusion record identifies parties excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non Financial assistance and benefits. Exclusions are also referred to as suspensions and debarments.
What are the disadvantages of Medicaid?
Disadvantages of Medicaid They will have a decreased financial ability to opt for elective treatments, and they may not be able to pay for top brand drugs or other medical aids. Another financial concern is that medical practices cannot charge a fee when Medicaid patients miss appointments.
Who pays for Medicaid?
The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP).
Can you have Medicare and Medicaid at the same time?
Yes. A person can be eligible for both Medicaid and Medicare and receive benefits from both programs at the same time.
SPOTLIGHT & RELEASES
10/20/2021: CMS released a Memo to Long Term Care Facilities on Disenrollment Issues . More information can be found below under "Enrollment & Disenrollment Memos."
Training Resources on Enrollment Processing
Appendix 5 is a state-specific document that contains a state's detailed description of policies related to enrollment, as well as Medicaid-specific requirements and functions.
MMP Enrollment Guidance Appendix 5
Appendix 5 is a state-specific document that contains a state's detailed description of policies related to enrollment, as well as Medicaid-specific requirements and functions.
How do Medicare and Medicaid work together?
For dual eligible beneficiaries, Medicare serves as the primary payer, and Medicaid acts as the secondary payer.
Who is dual eligible for Medicare and Medicaid?
To be Medicare dual eligible, you have to meet the requirements for Medicare and your state’s Medicaid program.
What is PACE for Medicare and Medicaid?
Another Medicare and Medicaid program is PACE, or Programs of All-Inclusive Care for the Elderly.
What is Medicare Extra Help?
Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy (LIS)
What is Medicare Savings Program?
A Medicare Savings Program (MSP) is a federally funded program administered within each state that helps lower income people pay for Medicare premiums, deductibles, copayments and coinsurance.
What is QMB in Medicare?
Qualified Medicare Beneficiary (QMB) Program. This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments. Eligibility requires: Income of no more than $1,061 per month for an individual in 2019, or $1,430 per month for a married couple.
Is Medicare the same as Medicaid?
Medicare eligibility is consistent for everyone across the U.S., no matter what state you live in. Medicaid is for people of any age who meet certain income qualifications. Medicaid is administered by state governments, and eligibility requirements can differ between states.
What is Medicare Part 50.3?
50.3 - Reinstatements for Invalid Disenrollments ................................................ 79 50.3.1 - Reinstatements for Disenrollment Due to Erroneous Death Indicator or Due to Errone ous Loss of Medicare Part A or Part B, Errone ous
When did Medicare start sending MBI?
Beginning in April 2018 , CMS started sending the new Medicare cards with the MBI to all Medicare beneficiaries. As of April 1, 2018, CMS is only sending the MBI on enrollment related reports and files. States and MMPs will need to be prepared to process enrollment related transactions using the MBI as of April 2018.
What is dual eligible Medicare?
serves people who are enrolled in both Medicare and Medicaid , also known as dual eligible beneficiaries. The goal of the Initiative is to ensure dual eligible beneficiaries have full access to seamless, high quality integrated health care. Through demonstrations under the capitated financial alignment model, integrated Medicare-Medicaid Plans (MMPs) enter into three-way contracts with CMS and states. The demonstrations also strive to simplify the processes for dual eligible individuals to access the care and services they are entitled to under Medicare and Medicaid programs. This includes providing beneficiaries with a seamless enrollment and disenrollment process as well as clear communication about that process. States play a critical role in this process by working with both CMS and MMPs to ensure that beneficiaries receive information about the demonstrations in clear and timely manner and are appropriately enrolled or disenrolled.
Can MMPs delegate to CMS?
In limited instances, and with advance notice to CMS states may delegate some of these activities to the MMPs, who must then comply with this guidance. However, states cannot delegate to MMPs the following:
Does 1915 waiver extend to Medicare?
This waiver authority does not extend to Medicare, so the individual’s Medicare benefits are not affected. For example, an individual may be enrolled in a Medicaid-only Managed Long Term Services and Supports (MLTSS) plan that has the same parent organization as the MMP. The Medicaid-only program is different and it is not to be confused with the three- way MMP contract as states have separate contracts with plans for the Medicaid-only managed care product.
Is a person eligible for medical assistance under a state plan?
5. The individual is eligible for Medical Assistance under a state plan under title XIX of the Social Security Act or under a waiver of such plan, and meets other criteria established by the state in the Memorandum of Understanding, the three-way contract, or as further detailed in Appendix 5.
Does MMP have additional eligibility requirements?
An MMP may not impose any additional eligibility requirements as a condition of enrollment other than those described in the Memorandum of Understanding (MOU), by the three-way contract among the MMP, state, and CMS; or as established by the state and CMS in this guidance, including Appendix 5.
What is the number to report Medicare fraud?
If you come across any agent misconduct, please report it to our California SMP at 1-855-613-7080.
Can Medicare send unsolicited calls?
Unsolicited phone calls or home visits (Note: in the updated Medicare Communications & Marketing Guidelines, agents CAN now send unsolicited emails as long as there is an opt out function in the email)
Can you enroll a Medicare beneficiary over the phone?
Enrolling a beneficiary in a Medicare Advantage or Supplement plan over the phone, unless the beneficiary initiated the call to enroll
What is the responsibility of CMS?
If a state informs CMS that it does not have authority to enforce one or more of the provisions of the Affordable Care Act, and the state has not entered into a collaborative arrangement, CMS has the responsibility to directly enforce the relevant provisions in the state with respect to health insurance issuers in ...
What is collaborative arrangement with CMS?
CMS will form a collaborative arrangement with any state that is willing and able to perform regulatory functions but lacks enforcement authority. To the extent that CMS and a state agree on a collaborative approach, the state will perform the same regulatory functions with respect to the Affordable Care Act market reform provisions as it does to ensure compliance with state law, and will seek to achieve voluntary compliance from issuers if the state finds a potential violation. Similarly, consumers will continue to contact the state for inquiries and complaints relating to the health insurance market reform requirements. Under this collaborative approach, if the state finds a potential violation and is unable to obtain voluntary compliance from an issuer, it will refer the matter to CMS for possible enforcement action.
Is CMS enforcing the Affordable Care Act?
The vast majority of states are enforcing the Affordable Care Act health insurance market reforms. Some states lack the authority, the ability to enforce these provisions, or both. CMS has responsibility for enforcing these requirements in a state that is not enforcing the health insurance market reforms either through a collaborative arrangement ...
Does CMS conduct examinations?
CMS will also conduct targeted market conduct examinations, as necessary, and respond to consumer inquiries and complaints to ensure compliance with the health insurance market reform standards. CMS will work cooperatively with the state to address any concerns. At any time, a state that is willing and able may assume enforcement authority ...
Does CMS notify issuers of any concerns?
To do so, CMS will notify issuers in the state that they must submit policy forms to CMS for review. After collection and review of policy forms for compliance with the respective market reform provisions, CMS will notify issuers of any concerns. CMS will also conduct targeted market conduct examinations, as necessary, ...
