Ariz. Admin. Code § 9-29-302

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-29-302 - QMB Dual Member

A. Covered services. A person determined to be a QMB Dual eligible member shall receive medical services provided under 9 A.A.C. 22, Article 2, or services provided under 9 A.A.C. 28, Article 2, in addition to the Medicare-related payments under R9-29-301(A).

B. Premiums. The Administration pays Medicare part A and B premiums for a QMB Dual member enrolled with a contractor in a plan or AHCCCS Fee-For-Service.

C. The Administration's payment responsibilities.

1. The Administration shall pay the following costs for members not enrolled with contractors. When services are received from an AHCCCS registered provider and the service is covered:

a. By Medicare only, the Administration shall pay the Medicare coinsurance and deductible.

b. By Medicaid only, the Administration shall pay the lesser of billed charges or the Capped Fee-For-Service Schedule rate for the services covered under 9 A.A.C. 22, Article 2 and 9 A.A.C. 28, Article 2.

c. By both Medicare and Medicaid, the Administration shall pay Medicare coinsurance and deductible.

2. When services are received from a non-registered provider and the service is covered, the Administration shall not pay the Medicare coinsurance and deductible.

D. The contractor's payment responsibilities. Unless the subcontract with the provider sets forth different terms, when the enrolled member receives services from an AHCCCS registered provider in or out of network and the service is covered:

1. By Medicare only, the contractor shall pay the Medicare coinsurance and deductible.

2. By Medicaid only, the contractor shall pay the provider in accordance with the contract.

3. By both Medicare and Medicaid, the contractor shall pay the lesser of:

a. The Medicare copay, coinsurance or deductible, or

b. The difference between the Health plan contracted rate and the Medicare paid amount.

E. Member responsibilities. A QMB Dual eligible member who receives services under 9 A.A.C. 22, Article 2 or 9 A.A.C. 28, Article 2 from a registered provider is not liable for any Medicare copay, coinsurance or deductible associated with those services and is not liable for any balance of billed charges.

F. Coordination of prescription drug benefit with Medicare Part D. Notwithstanding subsections (A) through (D), services do not include pharmaceutical services to the extent limited under 42 U.S.C. 1396u-5(d). A contractor is not liable for any Medicare copay, coinsurance or deductible associated with pharmaceutical services subject to the limitation under 42 U.S.C. 1396u-5(d).

Ariz. Admin. Code § R9-29-302

Adopted effective May 23, 1990 (Supp. 90-2). Amended effective April 14, 1998 (Supp. 98-2). Amended by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4). Amended by final rulemaking at 12 A.A.R. 864, effective March 7, 2006 (Supp. 06-1). Amended by final rulemaking at 18 A.A.R. 3139, effective January 6, 2013 (Supp. 12-4).