Dual-Eligible Special Needs Plan (D-SNP) billing 

PriorityMedicare D-SNP is Priority Health's dual-eligible special needs plan. Members with this plan are eligible for both Medicare and full Medicaid benefits. If you provide services to PriorityMedicare D-SNP members, review the below billing information. Note that this information applies to all dual-eligible beneficiaries, not just those enrolled in PriorityMedicare D-SNP. 

Billing prohibitions for dual-eligibles

Certain billing prohibitions apply to the dual eligible beneficiaries you serve. Federal law prohibits all Medicare providers and suppliers from billing dual-eligible beneficiaries (also known as Qualified Medicare Beneficiaries or QMBs) for Medicare Part A and Part B cost-sharing (i.e. copays, coinsurance or deductibles) under any circumstances. These beneficiaries have Medicaid coverage of Medicare Part A and Part B premiums and cost-sharing.

Providers and suppliers may bill State Medicaid agencies (Michigan Department of Community Health) for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, individuals enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.   

For more information, see MLN Matters SE1128 and Dually Eligible Beneficiaries Under Medicare and Medicaid (cms.gov).