Reimbursement Rates for Medicaid Clients in Medicare
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Reimbursement Rates for Medicaid Clients in Medicare


Revised April 25, 2013



Purpose: This clarification is based on the Dear Nursing Home Administrator letter NH #2010-001 sent 3/26/2010

Reimbursement rates for Medicaid clients enrolled in Medicare

For Medicaid clients enrolled in fee for service medicare (not Medicare Advantage plans), Medicare will pay in full for up to the first twenty days of nursing facility care at the full Medicare rate.  For the first day and up to eighty days thereafter (i.e. the hundred and first day), the amount paid by Medicare will be reduced by the client's co-insurance responsibility.  The department will pay up to the Medicaid rate for the co-insurance days.  This is described in WAC 182-502-0110 (3) and WAC 182-517-0320 (1) (d)  and 1902 n of the Social Security Act


Reimbursement rates for Qualified Medicare Beneficiaries (QMB) only clients

QMB-only clients are not eligible for Medicaid under the categorically needy (CN) or medically needy (MN) programs, but are eligible for payment of Medicare cost sharing expenses.

(NOTE:  A QMB only client may apply for a CN or MN program if medicaid is needed beyond the Medicare days in the nursing facility).

The department will pay for Medicare co-insurance charges for QMB-only residents, up to the medicaid nursing facility reimbursement rate.  It will not be necessary for a QMB-only resident to apply for Medicaid services for payment of co-insurance expense during Medicare coinsurance days.  QMB-only clients are not required to pay participation.  They will not be issued a Medicaid award letter.  An award letter is not required in order to bill the Department for these expenses.  Providers should refer to the nursing home billing instructions at the following link for instructions on how to bill for QMB-only claims:

Health Care Authority Billing Instructions (Provider Guides)

Nursing Facilities Billing Instructions (Provider Guides)

How to bill Medicare Crossovers in ProviderOne

QMB only clients are S03 in ACES and Provider One. 


Reimbursement rates for Medicaid clients enrolled in Medicare Part C (Advantage) plans

For Medicaid clients enrolled in Medicare Part C plans, payment for Medicare days including co-insurance days may vary depending on the Medicare C plan.  The department will pay up to the Medicaid rate for co-insurance days. 


Medicaid client participation during Medicare days including co-insurance days

Facilities may not collect participation from Medicaid clients during Medicare days, including Medicare co-insurance days.  Client participation which is indicated on the DSHS Medicaid award letter is only applicable for Medicaid days.

Client participation is not an eligibility factor for Medicare coverage.  This includes cases where the Medicaid rate is higher than the Medicare co-insurance rate and DSHS is billed for the co-insurance up to the Medicaid rate.  Clients or their representatives are responsible to report if their resources exceed Medicaid standards when clients are in Medicare status as they are not participating their monthly income toward the cost of care during Medicare days.

Please note:  The department cannot use Medicaid funds to pay the recipient's co-insurance responsibility beyond the amount Medicaid would pay for the service and cannot allow nursing facilities to write off the unpaid amounts as bad debts on their Medicaid cost reports. 

Nursing Home Providers may contact the Nursing Home Billing Unit at the Health Care Authority with questions regarding the billing during Medicare days. 

Modification Date: April 25, 2013