Cov Lus Qhia Txog Cov Nqi Them Nqi
Rov qab mus rau Cov Lus Qhia rau Cov Neeg Laus
Qhov nyiaj tshuav nqi yog dab tsi?
Dual eligible beneficiaries (“Medi-Medis”) are individuals with both Medicare and Medi-Cal. Medicare providers (like doctors and hospitals) cannot bill dual eligible beneficiaries for Medicare cost sharing. This is known as balance billing, or “improper billing,” and is illegal under both federal and state law. This means dual eligible beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. Similarly, this protection also applies to Qualified Medicare Beneficiaries (QMBs).
Dual eligible beneficiaries or QMBs should never receive a bill for Medicare cost sharing. These beneficiaries should not pay for physician visits and other medical care when they receive Medicare-covered services. For beneficiaries in a Medicare Advantage plan, including a Medi-Medi Plan, beneficiaries should not pay for medical care when they receive covered services from a provider in their plan’s provider network. This applies to both Medicare and Medi-Cal providers.
Even if a Medicare provider is not enrolled in Medi-Cal, the provider may not bill the dual eligible beneficiary. Please see additional resources below to learn more about balance billing.
- Cov Ntaub Ntawv Qhia Txog Cov Nqi Them Nqi Them Nqi
- Billing Protections for People with Medicare and Medi-Cal Video – American Sign Language Interpretation
Cov kev zam yog dab tsi?
Cov neeg tau txais txiaj ntsig ob leeg tuaj yeem tau txais daim nqi kho mob yog tias lawv muaj:
- Co-them rau cov tshuaj kho mob raws li Tshooj D;
- Ib hlis twg ntawm cov nqi them rau cov nqi Medi-Cal uas tsis tau them; thiab/los yog
- Kev pabcuam tsis them los ntawm Medicare lossis Medi-Cal.
Please note, certain administrative fees, such as for missed appointments or completing a form outside of an appointment, are not prohibited by federal guidance. However, charges for missed appointments must be the same as that assessed for non-Medicare patients.
Cov kws kho mob yuav tsum tau them nqi li cas rau cov kev pab them nqi Medicare?
Feem ntau, Medicare yuav them 80 feem pua ntawm cov nqi Medicare. Medi-Cal yog lub luag haujlwm rau txhua qhov kev sib faib nqi ntawm Medicare, nrog rau kev them nqi txwv rau Medi-Cal cov nqi them rov qab. Qhov no yog hu ua "crossover claim." Rau cov neeg tau txais txiaj ntsig hauv Original Medicare, Medicare Tus Thawj Saib Xyuas Kev Lag Luam ua cov txheej txheem tseem ceeb rau kev them nyiaj Medicare thiab tom qab ntawd xa daim ntawv thov mus rau Medi-Cal txoj kev npaj rau kev them nyiaj Medi-Cal thib ob. Rau cov neeg tau txais txiaj ntsig hauv Medicare Advantage (MA) cov phiaj xwm, cov kws kho mob yuav tsum tau them nqi MA txoj kev npaj them nqi Medicare thawj zaug, thiab sau nqi Medi-Cal txoj kev npaj rau cov nyiaj Medi-Cal thib ob.
Cov kws kho mob tsis tas yuav yog ib feem ntawm Medi-Cal txoj kev npaj lub network kom muaj cov ntaub ntawv hla dhau los ua tiav thiab them nyiaj. However, Medi-Cal plans will pay a physician who is an active Medi-Cal provider or a “Crossover Only” provider any amount owed under state Medi-Cal law. Please access the DHCS PAVE Tus Muab Kev Pabcuam Portal to enroll as a Medi-Cal provider or a “Crossover Only” Provider. Please see the DHCS Crossover Billing Toolkit.
Tus neeg tau txais txiaj ntsig zoo dua yuav ua li cas yog tias tus kws kho mob tau them nqi?
If a health care provider has billed a dual eligible beneficiary for a Medi-Cal or Medicare covered service, the beneficiary should not pay the bill. Instead, the beneficiary should first try to resolve the issue with their health care provider, to tell them they should not have been billed because they receive both Medicare and Medi-Cal.
Providers must take immediate actions to fix the issue once they know that a beneficiary is dually eligible. The provider must refund any amounts already paid, stop the bill collection process, and work with credit reporting agencies to correct any issues caused by billing dual eligible beneficiaries. Providers can refer to the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN) Matters Article for additional information.
Yog tias tus kws kho mob tsis tso tseg cov txheej txheem sau nqi, ces tus neeg tau txais txiaj ntsig ob leeg yuav tsum hu rau lawv qhov kev npaj kho mob MA tam sim los daws qhov teeb meem lossis hu rau (800) MEDICARE ((800) 633-4227) yog tias lawv tau cuv npe hauv Original Medicare.
Yog tias tsis yog tus kws kho mob lossis cov phiaj xwm kev noj qab haus huv daws qhov teeb meem, ces ib tus neeg tau txais txiaj ntsig ob leeg tuaj yeem hu rau Medicare Medi-Cal Ombudsman ntawm (855) 501-3077 kom nug cov lus nug txog yuav ua li cas ntxiv tom ntej lossis hu rau California Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv Kev Pabcuam Center ntawm (888) 466-2219 mus sau ntawv tsis txaus siab.
Hom Kev Tsim Nyog Muaj Peev Xwm Ob
Cov kev tsim nyog dual muaj xws li ob qho tag nrho dual thiab ib nrab dual.
Full Duals
"Kev tsim nyog tau txais ob npaug" txhais tau hais tias ib tus neeg tsim nyog rau Medicare thiab Medi-Cal. Txhawm rau kom muaj kev tsim nyog tau txais ob npaug, nws txhais tau tias koj tsim nyog tau txais cov txiaj ntsig Medi-Cal tag nrho hauv xeev thiab rau Medicare. Ib tus neeg uas tsim nyog tau txais kev tsim nyog tau txais ob npaug kuj tseem tuaj yeem tsim nyog rau Dual Special Needs Plan (D-SNP). Nov yog hom phiaj xwm Medicare Advantage uas muaj cov txiaj ntsig zoo tshaj li Medicare thiab Medicaid ib txwm muaj.
Medicare them rau feem ntau ntawm cov kev pab them nqi kho mob thiab cov txiaj ntsig, tab sis Medi-Cal them qee cov nqi tawm hauv hnab tshos rau cov nqi them, nyiaj npib, cov nqi txiav tawm thiab cov nqi them. Medi-Cal kuj tseem them cov txiaj ntsig uas tsis tau them los ntawm Dual Special Needs Plan, xws li kev saib xyuas mus sij hawm ntev.
Ib nrab Duals
“Ib feem ntawm kev tsim nyog ob leeg” txhais tau hais tias ib tus neeg tsim nyog tau txais Medicare Savings Program (MSP) tab sis tsis tau rau npe hauv Medi-Cal. MSPs yog tswj hwm los ntawm Medicaid program hauv txhua lub xeev. Thaum MSPs them rau qee cov nqi Medicare, xws li Medicare Part A thiab Part B cov nqi them, cov neeg uas muaj kev tsim nyog ob feem tsis tau txais cov txiaj ntsig kho mob tag nrho ntawm Medicaid.
Cov peev txheej ntxiv
Cov ntaub ntawv ntxiv txog kev tiv thaiv kev tiv thaiv kev tshuav nqi tuaj yeem pom hauv: