37.83.825    QUALIFIED MEDICARE BENEFICIARIES, PAYMENTS TO PROVIDERS

(1) Payments for services provided to medicaid qualified medicare beneficiaries may only be made to a provider. A provider in order to receive payments must be enrolled in the medicaid program.

(a) Medicaid payment will be made to the provider even when the provider for medicare purposes has not accepted assignment.

(2) Payment in full, except as otherwise provided in (2) (a) below, for services provided to medicaid qualified medicare beneficiaries, is the medicaid payment as determined under ARM 37.83.811, 37.83.812 and 37.85.406 plus the qualified medicare beneficiary's copayment as provided for in ARM 37.83.826. A provider may not collect any amount from the person which is in excess of payment in full even if that payment is less than the medicare insurance deductibles and coinsurance. Where a person is eligible for medicaid under both medicaid qualified medicare beneficiary and another medicaid category, a provider must accept the medicaid payment as payment in full.

(a) Where a provider does not accept medicare assignment and the person receiving medicaid services is medicaid eligible only as a qualified medicare beneficiary, the provider may bill the person for that portion of the service cost that is the difference between medicare's allowable rate and the provider's charge. A provider who does not accept medicare assignment must inform a person receiving services that this portion may be billed to the person.

(3) Subject to the requirements of this rule, the Montana medicaid program pays the lowest of the following for qualified medicare beneficiary services:

(a) the provider's usual and customary charge for the service; or

(b) the appropriate medicaid allowed amount as provided in ARM 37.85.406(18) .

History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-6-101 and 53-6-131, MCA; NEW, 1989 MAR p. 835, Eff. 6/30/89; TRANS, from SRS, 2000 MAR p. 197; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01.