Section 471-30-004 - REIMBURSEMENTSMedicaid covers reimbursement of premiums for Medicaid-eligible enrollees in a cost effective group health plan or individual market health plan. Medicaid also covers payment of all deductibles, coinsurance, and other cost sharing obligations under the group health plan or individual market health plan that are for services covered under the Medicaid State Plan.
Reimbursements will be made directly to the policyholder as a reimbursement for the group health insurance or individual market health insurance premiums. The client or policyholder must submit accompanying documentation within sixty days of the date paid showing the premium payment has been made.
004.01FAMILY MEMBERS. If a family member who is not eligible for Medicaid must be enrolled in the group health plan or individual market health plan to obtain coverage under the group health plan or individual market health plan for the Medicaid-eligible client, Medicaid covers payment for the group health plan premiums for the family member who is not eligible for Medicaid.004.02DEDUCTIBLES, COINSURANCE, AND OTHER COST SHARING. The Department will pay deductibles, co-insurance, and cost sharing obligations up to the Medicaid allowable amounts directly to the enrolled Medicaid provider. The provider must submit a claim to the Department in accordance with claim submission and payment guidelines outlined in 471 NAC Chapters 2 and 3, as well as any submission and payment guidelines included within each service specific NAC Title 471 Chapter directly. Payment will be made directly to the provider in an amount up to, but not exceeding, the Medicaid allowable amount less any payment made to the provider by the group health plan or individual market health plan. The provider must accept Medicaid payment as payment in full, and cannot bill the client for the difference between the Medicaid payment and the billed amount. Prior to submitting a claim to the Department for payment, the provider must complete the provider enrollment process outlined in 471 NAC Chapter 2 as well as any enrollment requirements included within each service specific NAC Title 471 Chapter.
004.02(A)FAMILY MEMBERS. Medicaid does not cover deductibles, coinsurance, and other cost sharing obligations under the group health plan or individual market health plan for any family member who is not eligible for Medicaid.004.03SERVICES COVERED BY MEDICAID. A client's enrollment in a group health plan or individual market health plan does not change the client's eligibility for benefits under Medicaid. If services covered under Medicaid are not covered by the group health plan or individual market health plan, the client may obtain these services from Medicaid-enrolled providers. Coverage of, and payment for those services is made according 471 NAC Chapters 1, 2, and 3, as well as well as any coverage and payment requirements included within each service specific NAC Title 471 Chapter. If a client is enrolled in Managed Care to obtain services, the coverage and subsequent payment for those services will be in accordance with the Managed Care entities' coverage and payment guidelines.004.04SERVICES NOT COVERED BY MEDICAID. Medicaid does not pay for the deductibles, coinsurance, and other cost sharing obligations for services covered under the client's group health plan or individual market health plan that are not covered under the Nebraska Medicaid State Plan.004.05MEDICARE ENROLLMENT. If the client is also eligible for Medicare but is not enrolled in Medicare, Medicaid does not pay for the premiums or other cost sharing obligations to the group health plan or individual market health insurance.471 Neb. Admin. Code, ch. 30, § 004
Adopted effective 7/1/2019