Medicaid Coverage of Co-Insurance for Medicare Part B Immunosuppressant Drugs

On January 1, 2012, HHSC changed the reimbursement methodology for claims submitted to Medicaid as the secondary payer after Medicare has paid its share ― also called “crossover claims.” This change caused some crossover claims for immunosuppressant and other Part B drugs to pay at zero. These claims may be eligible for reimbursement, and HHSC is working on a solution to allow you to resubmit them. In the meantime, please continue to provide immunosuppressant drugs to your Medicaid/Medicare patients. HHSC will work with you to provide appropriate reimbursement for those prescriptions and prescriptions that you have already filled. 

 

Medicaid clients who are also covered by Medicare (dual eligibles) may have all or a portion of their co-insurance and deductible amounts paid by Medicaid. For a crossover claim for an immunosuppressant or other specified Part B drugs dispensed to a dual eligible client after the changes implemented January 1, 2012, your total payment from Medicare and Medicaid combined should be no less than the lower of the Medicaid rate or the Medicare rate for the drug. 

 

HHSC is researching the quickest short-term and best long-term solution to reinstating correct payment for Medicare Part B co-insurance for those prescription drugs that are a benefit of Medicaid. We will notify pharmacies as soon as possible with specific instructions for resubmitting previously processed claims and for submitting future prescription claims. As long as your claim is otherwise payable (e.g., eligible Medicaid client, covered drug, etc.) you will receive the appropriate payment from HHSC. 

 

While HHSC develops a process to allow you to submit/resubmit crossover claims, we ask you to continue to provide critical and life-saving medications to your most vulnerable patients. Please keep in mind that you may not request payment directly from your Medicaid customers.

 

If you previously submitted your crossover claims to the Texas Medicaid Healthcare Partnership, you may be able to submit claims immediately for some of your dual-eligible patients to the Vendor Drug Program (VDP) Pharmacy claims system. If you submit an Eligibility Verification transaction to the VDP system (through your point-of-sale system) and get an affirmative response, then you can submit your prescription drug claim to the VDP system. Please contact the VDP Pharmacy Resolution Help Desk for assistance, at 1-800-435-4165.