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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions
12/22/2024

12VAC30-10-320. Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance.

A. Medicare Part A and B. 12VAC30-80-170 describes the methods and standards for establishing payment rates for services covered under Medicare, and/or the methodology for payment of Medicare deductible and coinsurance amounts, to the extent available for each of the following groups.

1. Qualified Medicare Beneficiaries (QMBS). The Medicaid agency pays Medicare Part A and Part B deductibles and coinsurance amounts for QMBs (subject to any nominal Medicaid copayment) for all services available under Medicare.

2. Other Medicaid Recipients. The Medicaid agency pays Medicaid services also covered under Medicare and furnished to recipients entitled to Medicare (subject to any nominal Medicaid copayment). For services furnished to individuals who are described in 12VAC30-10-310 A 4, payment is only for the amount, duration, and scope of services otherwise available under this plan.

3. Dual Eligible--QMB plus. The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance amounts for all services available under Medicare and pays for all Medicaid services furnished to individuals eligible both as QMBs and categorically or medically needy (subject to any nominal Medicaid copayment).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29.3, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

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