The commission must identify dual Medicaid/Medicare individuals and review claims so Medicare is billed first when allowed; certain providers must bill Medicare first, with a home-health exception.
Sec. 32.050. DUAL MEDICAID AND MEDICARE COVERAGE. (a) At least annually the commission shall identify each individual receiving medical assistance under the medical assistance program who is eligible to receive similar assistance under the Medicare program. (b) The commission shall analyze claims submitted for payment for a service provided under the medical assistance program to an individual identified under Subsection (a) to ensure that payment is sought first under the Medicare program to the extent allowed by law. (c) For an ambulance service provided to an individual who is eligible under the medical assistance program and Medicare, the medical assistance program shall pay the Medicare deductibles and coinsurance. (d) Except as provided by Subsection (e), a nursing facility, a home health services provider, or any other similar long-term care services provider that is Medicare-certified and provides care to individuals who are eligible for Medicare must: (1) seek reimbursement from Medicare before billing the medical assistance program for services provided to an individual identified under Subsection (a); and (2) as directed by the commission, appeal Medicare claim denials for payment services provided to an individual identified under Subsection (a). (e) A home health services provider is not required to seek reimbursement from Medicare before billing the medical assistance program for services provided to a person who is eligible for Medicare and who: (1) has been determined as not being homebound; or (2) meets other criteria determined by the executive commissioner. (f) Repealed by Acts 2005, 79th Leg., Ch. 1067, Sec. 1, eff. June 18, 2005. Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.03(a), eff. June 20, 1997. Amended by Acts 1999, 76th Leg., ch. 710, Sec. 1. Renumbered from Sec. 32.043 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(76), eff. Sept. 1, 1999; Acts 2003, 78th Leg., ch. 198, Sec. 2.108, eff. Sept. 1, 2003. Amended by: Acts 2005, 79th Leg., Ch. 1067 (H.B. 1502), Sec. 1, eff. June 18, 2005. Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.125, eff. April 2, 2015.