Section R9-29-303. Non-QMB Dual Member

A.      Covered services. A person determined to be a Non-QMB Dual eligible member shall receive medical services and pro- visions under 9 A.A.C. 22, Article 2, or services and provi- sions under 9 A.A.C. 28, Article 2.

B.       Premiums. The Administration pays Medicare part B premi- ums for a Non-QMB dual member enrolled with a contractor in a plan or AHCCCS Fee-For-Service for the following indi- viduals:

1.        An individual described in 42 CFR 431.625;

2.        An individual enrolled in ALTCS but who does not qual- ify as a QMB, SLMB or QI;

3.        An individual who is eligible for Medicaid under a man- datory or optional Title XIX coverage group for the aged, blind, or disabled (SSI-MAO);

4.        An individual who is eligible for continued coverage while eligibility redetermination is pending as described under 42 CFR 435.1003;

5.        An individual who is in the guaranteed enrollment period described in 42 CFR 435.212 and the state was paying the individual’s Part B premium before eligibility terminated.

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 up to the limitations described within 9 A.A.C. 22, Article 2:

a.        By Medicare only, the Administration shall not pay the Medicare copay, coinsurance or deductible.

b.        By Medicaid only, the Administration shall pay the lesser of billed charges or the Capped Fee-For-Ser- vice 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 the Medicare copay, coinsurance or deductible.

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

D.      The contractor’s payment responsibilities.

1.        When an enrolled member receives services within the network of contracted providers and the service is cov- ered up to the limitations described within 9 A.A.C. 22, Article 2:

a.        By Medicare only, the contractor shall not pay the Medicare copay, coinsurance or deductible.

b.        By Medicaid only, the contractor shall pay the pro- vider in accordance with the subcontract.

c.        By both Medicare and Medicaid, unless the subcon- tract with the provider sets forth different terms, the contractor shall pay the lesser of:

i.         The Medicare copay, coinsurance or deductible, or

ii.        Any amount remaining after the Medicare paid amount is deducted from the subcontracted rate.

2.        When an enrolled member receives services from a non- contracting provider and the service is covered:

a.        By Medicare only, the contractor has no responsibil- ity for payment.

b.        By Medicaid only, and the contractor has not referred the member to the provider or has not authorized the provider to render services and the services are not emergent, the contractor has no responsibility for payment.

c.        By Medicaid only, and the contractor has referred the member to the provider or has authorized the provider to render services or the services are emer- gent, the contractor shall pay in accordance with

A.A.C. R9-22-705.

d.        By both Medicare and Medicaid, and the contractor has not referred the member to the provider or has not authorized the provider to render services and the services are not emergent, the contractor has no responsibility for payment.

e.        By both Medicare and Medicaid, and the contractor has referred the member to the provider or has authorized the provider to render services or the ser- vices are emergent, the contractor shall pay the lesser of:

i.         The Medicare copay, coinsurance or deduct- ible, or

ii.        Any amount remaining after the Medicare paid amount is deducted from the amount otherwise payable under A.A.C. R9-22-705.

E.       Member responsibilities.

1.        A Non-QMB Dual eligible member who receives covered services under 9 A.A.C. 22, Article 2 or 9 A.A.C. 28, Article 2 from a provider within the contractor’s network is not liable for any Medicare copay, coinsurance or deductible associated with those services and is not liable for any balance of billed charges unless services have reached the limitations described within 9. A.A.C. 22, Article 2.

2.        When an enrolled member chooses to receive services out of network that are covered by both Medicare and Medic- aid, the member is responsible for any Medicare copay, coinsurance or deductible associated with those services unless  the  contractor   is  responsible  as  described   in

A.A.C. R9-22-705 and the provider has complied with

A.A.C. R9-22-702.

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 Medi- care copay, coinsurance or deductible associated with pharma- ceutical services subject to the limitation under 42 U.S.C. 1396u-5(d).

Historical Note

New Section made by final rulemaking at 9 A.A.R. 5142, effective January 3, 2004 (Supp. 03-4). Section R9-29- 303 repealed; new Section R9-29-303 made by final rulemaking at 18 A.A.R. 3139, effective January 6, 2013

(Supp. 12-4).