In 2017 Applied Policy connected with a large DME supply company seeking crossover claim reimbursement for Qualified Medicare Beneficiaries (QMB) in Massachusetts. Operating in the competitive mail-order supply sector, the company delivers insulin pumps and related supplies to individuals in MA. The state was not paying the Medicaid portion of the claim because MA requires a physical presence in the state in order to be reimbursed by MA. Medicaid.  The state has this authority for Medicaid only claims, it is a violation of Medicare rules when the beneficiary is a QMB.

Drawing on their knowledge of Medicare and Medicaid regulations, the Applied Policy team recognized the distinction between the requirements of a Medicaid primary supplier and those of a supplier billing Medicaid for QMB cost sharing when a state’s Medicaid program is the secondary payer. Centers for Medicare & Medicaid Services (CMS) regulations specifically require all state Medicaid programs to provide a means for any Medicare provider or supplier to be able to receive the cost sharing amount of a valid claim for dually-eligible Medicare and Medicaid beneficiaries.

One of Applied Policy’s staff formerly served as a Senior Advisor at CMS and had helped to write the supporting guidance for these requirements.  Applied Policy contacted the appropriate CMS personnel in the Baltimore headquarters as well as those in the Boston regional office to report MA’s non-compliance.  Through these efforts, Applied Policy was given a direct point of contact at MA’s Medicaid contractor, MassHealth. Applied Policy provided MassHealth with the specific citation in the regulations and supporting documentation showing that our client was allowed to bill for MA Medicaid for QMBs who require diabetes equipment and supplies.

Armed with the appropriate application and supporting documentation, Applied Policy guided the client through the application process and continued engagement with MassHealth until the issue was resolved. As a result, the client was properly enrolled as a MA Medicaid supplier for QMB-only claims and was eligible to receive reimbursement for supplies shipped into MA.