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