Billing for Medicare-Medicaid Dual Eligibles under Community HealthChoices: FAQs

Last Updated: Jun 18, 2019

Eldery-patient-wheelchairThe Centers for Medicare and Medicaid Services’ (CMS) Philadelphia Regional Office often receives questions about billing for Medicare-Medicaid dually eligible patients under Pennsylvania’s Community HealthChoices long-term care program. To address these questions, CMS has shared the below article, including answers to FAQs, with the Pennsylvania Medical Society (PAMED).

Pennsylvania is changing how it delivers Medicaid services for your patients with Medicare and Medicaid. While this will not change how you bill for Medicare services, it will change how you bill Medicaid for Medicare coinsurance and deductibles.

Community HealthChoices (CHC) is Pennsylvania’s new, mandatory Medicaid managed care program for individuals who are eligible for both Medicaid and Medicare (dual eligibles), as well as for other older adults and individuals with physical disabilities who have Medicaid. The Commonwealth designed CHC to serve more people in communities while giving them the opportunity to work, spend more time with their families, and experience an overall better quality of life.

CHC began on Jan. 1, 2018 in the 14 counties in the Southwest part of the state. On Jan 1, 2019, CHC started in Southeast Pennsylvania (Bucks, Chester, Delaware, Montgomery, and Philadelphia counties). It will roll out to the remainder of the state on Jan. 1, 2020. More information on CHC is available here.

Promoting improved coordination between Medicare and Medicaid is a key goal of CHC. Better coordination between these two payers can improve participant experiences and outcomes.

Both Medicare and Medicaid cover physical health services such as doctor visits, hospital stays, lab tests, and pharmaceuticals. Medicaid is the payer of last resort. Once Medicare — and any other health insurance coverage the participant has — have paid or denied the claim, Medicaid can be billed for the remainder of the claim. This does not change under CHC. Here is how it works:

  • Dually eligible participants continue to have all of the Medicare options they had prior to CHC, including Original Medicare and Medicare Advantage. Their Medicare coverage does not change unless they decide to change it.
  • Medicare continues to be the primary payer for any service covered by Medicare. Providers should continue to bill Medicare for eligible services prior to billing Medicaid. CHC does not change the services that are covered by Medicare.
  • Under CHC, all Medicaid bills for participants are submitted to the participant’s CHC-managed care organization (CHC-MCO), including bills that are submitted after Medicare has denied or paid part of a claim. Medicare and Medicaid providers no longer send these bills directly to the Pennsylvania Department of Human Services.
  • Providers cannot bill dually eligible participants for Medicare cost sharing when either Medicare or Medicaid does not cover the entire amount billed for a service delivered.

Frequently Asked Questions 

  1. How can a provider check whether a Medicare beneficiary is also a CHC participant or has other supplemental insurance coverage?
    Providers can check the Eligibility Verification System (EVS) to determine if a beneficiary is eligible for Medicaid and whether the beneficiary is also enrolled in CHC. EVS will identify the participant’s CHC-MCO and will identify any third-party resource (TPR), including Medicare, information. Since not all Medicaid beneficiaries will be dually enrolled in Medicare, at the time of service, providers should always ask participants to show all forms of insurance, including their Medicare card (Original or Medicare Advantage), CHC-MCO insurance card or ACCESS card or Medigap insurance card, a type of insurance that supplements Original Medicare coverage.
  2. What is the billing procedure for Medicare cost-sharing and how can providers test the claims process?
    Providers will need to send a claim to the appropriate CHC-MCO to receive payment for any covered cost-sharing for Medicare services. CHC-MCOs are required to train providers on claims submission, electronic visit verification systems, and other software systems such as service coordination system. Remember, you are prohibited from billing the patient for cost-sharing!
  3. Do providers have to join a CHC-MCO’s network in order to bill the CHC-MCO for the Medicaid portion of a Medicare-covered service?
    No. CHC-MCOs must pay participants’ Medicare co-insurance or deductible, whether or not the Medicare provider is included in the CHC-MCO’s network.
  4. How can providers find out more about CHC-MCO?
    More information is available at Providers with additional questions should visit or call the CHC Provider Hotline at 833-735-4417.

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