Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-05 - Medicaid coordination of benefits with the medicare program (Title XVIII)

Current through all regulations passed and filed through July 1, 2024
Paragraphs (A)(7) to (F)(4) of this rule do not apply to
				pharmacy services covered under the medicare part D program. Pharmacy services
				covered under the medicare part D program should be billed in accordance with
				rule 5160-9-06 of the Administrative Code.
(A) Definitions.
(1) "Medicare" is a federally financed
			 program of hospital insurance (part A) and supplemental medical insurance (also
			 called SMI or part B) for aged and
			 disabled persons.
(2) "Medicare
			 Benefits" means the health care services available to
			 an
			 individual through the medicare program where payment for the services
			 is either
			 completely the obligation of the medicare program or in part the obligation of
			 the medicare program with the remaining payment obligations belonging to the
			 individual, some other third party payer, or
			 medicaid.
(3) "
									Traditional
			 Medicare " is a health plan that pays for medicare benefits provided
			 to 
									individuals on a fee-for-service basis.
(4) "Medicare Advantage Plan (also known as
			 medicare part C plan)" is a managed care delivery system that includes coverage
			 for both hospital insurance and SMI, but the delivery of health care services
			 are contracted to and provided by an approved medicare managed care plan,
			 preferred provider organization, private fee-for-service plans, or medicare specialty plans.
(5) "Medicare Cost Sharing"
			 for the purpose of this rule means the portion of
			 a medicare crossover claim paid by medicaid.
(6) "Dual Eligibles or Dually Eligible
			 Individuals" are individuals who are entitled to
			 medicare hospital insurance and SMI and
			 are eligible for medicaid to pay some form of medicare cost sharing. The
			 following is a list of dual eligibles or dually
			 eligible individuals that qualify to have medicaid pay all or part of the
			 cost sharing portion of a paid medicare claim:
(a) "Qualified Medicare Beneficiaries without
			 Other Medicaid (QMB Only)" are individuals entitled to medicare hospital
			 insurance, have income of one hundred per cent of the federal poverty level
			 (FPL) or less and resources that do not exceed the
			 maximum amount of resources allowed under section 1905(p)(1) of the Social
			 Security Act (as in effect on October 1, 2018), as adjusted annually according
			 to the change in the consumer price index for urban areas (CPI-U), and are not otherwise eligible for full medicaid
			 benefits.
(b) "QMBs with Full
			 Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance,
			 have incomes of one hundred per cent FPL or less and resources that do not
			 exceed the maximum amount of resources allowed under
			 section 1905(p)(1) of the Social Security Act (as in effect on October 1,
			 2018), as adjusted annually according to the change in the consumer price index
			 for urban areas (CPI-U), and are eligible for full medicaid benefits.
(c) "Specified Low-Income Medicare
			 Beneficiaries with Full Medicaid (SLMB Plus) " are individuals entitled to
			 medicare hospital insurance, have income of greater than one hundred per cent
			 FPL, but less than one hundred twenty per cent FPL and resources that do not
			  exceed twice the limit for SSI
			 eligibility, and are eligible for full medicaid benefits.
(d) "Medicaid Only Dual Eligibles (for
			 example Non QMB)" are individuals entitled to medicare hospital insurance
			 and SMI and are eligible for full
			 medicaid benefits. They are not eligible for medicaid in any of the other dual
			 eligible categories (for example QMB).
(7) "Medicare Crossover Claim" means any
			 claim that has been submitted to the Ohio department of
			 
									medicaid (ODM) for medicare cost sharing payments
			 after the claim has been adjudicated and paid by the medicare central
			 processor, medicare carrier/intermediary or the medicare managed care plan
			 . Claims denied by the medicare carrier/intermediary
			 or the medicare managed care plan are not considered medicare crossover claims.
			 See paragraphs (E) and (F) of this rule for policy on services denied or not
			 covered by medicare.
(a) "Automatic Crossover
			 Claim" is a medicare claim submitted to ODM via the
			 automatic medicare crossover process described in paragraph (B)(2)(a) of this
			 rule.
(b) "Provider-Submitted
			 Crossover Claim" means a medicare crossover claim submitted to
			 ODM as
			 described in paragraph (B)(2)(b) of this rule.