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COMAR 10.09.24.03

349 State of Maryland Medical Assistance Manual Revised July 2012 The notice includes a full explanation of what Medicare was billed for, what was paid, what was not paid and whether the provider accepted the Medicare reimbursement as payment in full. If the provider billed for a higher rate than Medicare pays, and the provider does not accept the Medicare reimbursement as payment in full, the Medicare Summary Notice will include the fact that the beneficiary is responsible for the difference between the amount that Medicare actually paid and the actual charges. However, since the Medicare Beneficiary is enrolled in the Buy-in coverage, local departments will disregard that information for spend-down purposes with the exception that follows, assuming the beneficiary does not have a Medicare supplemental policy such as Blue Shield.

The remaining amount owed for services other than an inpatient hospital bill may be applied to excess income if the provider has billed the MA Program and the Program has refused payment because the Program will not pay for services in excess of what Medicare has paid. In this instance, the additional charges may be applied to excess income for spend-down purposes.

(j) Dually Eligible Persons Medicare beneficiaries who are eligible for MA are also eligible for the Buy-In coverage concurrent with their MA eligibility. This group is referred to as dually eligible. The Medical Care Operations Administration (MCOA) will, on the basis of the reported Medicare coverage, imprint QMB on the Medicare beneficiary MA card. No additional action for the Buy-in coverage is required of the local department for the initial certification. The Buy-in coverage has been, in the past, a regular part of MA coverage for Medicare beneficiaries who qualify for MA. That coverage will continue. The single difference is that under the new law, Federal Financial Participation (FFP) is available to the State for the payment of the Medicare Buy-in premiums, whereas, currently, the total premium is paid from state general funds. As a result of the availability of FFP, MA eligible persons must be certified for the Buy-in Coverage. (k) Specified Low-Income Medicare Beneficiaries (SLMB) In 1993, the Specified Low-Income Medicare Beneficiaries became effective with only one income standard. SLMB is a person: Who is entitled to Medicare hospital benefits under Part A; Who is not otherwise eligible for MA due to excess income or resources; Whose resources do not exceed the QMB resource limit, and; Whose countable income exceeds 100% of Federal Poverty level but does not exceed 120% of the Federal poverty level. SLMB Eligibility Criteria