Nursing home claims are currently being processed after Long Term Care/Third Party Liability (LTC/TPL) carriers using the lesser-than logic. These claims should pay up to the MaineCare rate after the LTC/TPL payment. We will notify you when this issue is
February 21, 2014
This change applies to those eligible for QMB without other Medicaid coverage (QMB only). Effective January 1, 2014, the Department limited cost sharing payments to hospital and nursing facility providers in the amount necessary to provide a total payment equal to the amount MaineCare would pay for these services under the State Plan. On January 31, 2014, we notified you that these claims would pend for Edit 6046 -Hosp NH QMB. This edit to pend claims has now been lifted and these claims will now be released for payment. No provider action is needed.
Reminder: Providers are strictly prohibited, under 42 USC §1396a(n)(3), from seeking to collect any amount from a QMB for Medicare deductibles or coinsurance, even if the MaineCare payment is less than the total amount of the Medicare deductible and coinsurance. Providers are, however, allowed to collect from the QMB Member any MaineCare copayment for the service.