Wis. ForwardHealth Online Handbook, Hospice, Topic #686

Professional Crossover Claims

State law limits reimbursement for coinsurance and copay of Medicare Part B-covered services provided to dual eligibles and

QMB-Only (Qualified Medicare Beneficiary-Only) members.

Total payment for a Medicare Part B-covered service (for example, any amount paid by other health insurance sources, any

copay or spenddown amounts paid by the member, and any amount paid by Wisconsin Medicaid) may not exceed the Medicare-allowed amount. Therefore, Medicaid reimbursement for coinsurance or copay of a Medicare Part B-covered service is the lesser

of the following:

• The Medicare-allowed amount less any amount paid by other health insurance sources and any copay or spenddown

amounts paid by the member.

• The Medicaid-allowed amount less any amount paid by other health insurance sources and any copay or spenddown

amounts paid by the member.

The following table provides three examples of how the limitations are applied.

Outpatient Hospital Crossover Claims

Detail-level information is used to calculate pricing for all outpatient hospital crossover claims and adjustments. Details that

Medicare paid in full or that Medicare denied in full will not be considered when pricing outpatient hospital crossover claims.

Medicare deductibles are paid in full.

Inpatient Hospital Services

State law limits reimbursement for coinsurance, copay and deductible of Medicare Part A-covered inpatient hospital services for

dual eligibles and QMB-Only members.

Wisconsin Medicaid's total reimbursement for a Medicare Part A-covered inpatient hospital service (for example, any amount

paid by other health insurance sources, any copay or deductible amounts paid by the member, and any amount paid by Wisconsin

Medicaid or BadgerCare Plus) may not exceed the Medicare-allowed amount. Therefore, Medicaid reimbursement for

coinsurance, copay, and deductible of a Medicare Part A-covered inpatient hospital service is the lesser of the following:

• The difference between the Medicaid-allowed amount and the Medicare-paid amount.

• The sum of Medicare coinsurance, copay, and deductible.

The following table provides three examples of how the limitations are applied.

Reimbursement for Coinsurance or Copay of Medicare Part B-Covered Services

Explanation Example

1 2 3

Provider's billed amount $120 $120 $120

Medicare-allowed amount $100 $100 $100

Medicaid-allowed amount (for example, maximum allowable fee) $90 $110 $75

Medicare payment $80 $80 $80

Medicaid payment $10 $20 $0

Nursing Home Crossover Claims

Medicare deductibles, coinsurance, and copays are paid in full.

Community Health Center and Tribal Federally Qualified Health Center

Crossover Claims

CHC (Community health center) and Tribal FQHC (federally qualified health center) encounters subject to PPS (prospective

payment system) and AIR (all-inclusive rate) reimbursement are carved out of (not included in) Medicare Crossover coverage.