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PA Bulletin, Doc. No. 97-1364



Office of Medical Assistance Program; Payment of Medicare Cost-sharing Amounts for Qualified Medicare Beneficiaries

[27 Pa.B. 4398]

   The purpose of this announcement is to provide notice under 42 CFR 447.205 that the Department of Public Welfare (Department) intends to amend its Medical Assistance State Plan to limit the Department's liability for payment of Medicare cost-sharing amounts (deductibles, coinsurance or copayments) relating to services rendered to Qualified Medicare Beneficiaries [QMBs] to the applicable Medical Assistance fee schedule or other payment amounts.

   Prior to the decision of the Third Circuit Court of Appeals in Pennsylvania Medical Society v. Snider, 29 F.3d 886 (3rd Cir. 1994), the Department paid Medicare cost-sharing amounts relating to certain services rendered to QMBs only if the Medicare payment for the service was less than the applicable Medical Assistance payment amount. To comply with the Third Circuit's decision in Pennsylvania Medical Society, the Department amended its State Plan to provide for payment of full Medicare cost-sharing amounts for outpatient services to QMBs. Recent clarifying amendments to Title XIX of the Social Security Act enacted as part of the Balance Budget Act of 1997, P. L. 105-33, § 4714(a), state, in pertinent part, that:

[A] State is not required to provide any payment for any expenses incurred relating to payment for deductibles, coinsurance, or copayments for medicare cost-sharing to the extent that payment under title XVIII for the service would exceed the payment amount that otherwise would be made under the State plan under this title [XIX] for such service if provided to an eligible recipient other than a medicare beneficiary.

   As a result of these Federal statutory amendments, the Department will amend its State Plan to specify that the Department will not pay Medicare cost-sharing amounts related to any services to the extent that payments made under the Medicare Program exceed the payments that would be made by the Medical Assistance Program for such services if provided to an eligible Medical Assistance recipient. The amendment will also provide that, if the Medical Assistance payment amount for a service exceeds the Medicare payment, the Department will pay Medicare cost-sharing amounts up to the amount of the deductible, coinsurance or copayment, or the applicable Medical Assistance payment amount, whichever is less. In addition, the amendment will reaffirm the Department's existing policies to the extent that they likewise limit payment of Medicare cost-sharing amounts relating to services provided by, among others, nursing facilities, to the applicable Medical Assistance payment rates for such services.

   The estimated decrease in aggregate expenditures during fiscal 1997-98 resulting from this amendment is $49.075 million in total funds ($23.126 million in State funds).

   A copy of this notice is available for review at the local County Assistance Offices throughout this Commonwealth. Interested persons are invited to submit written comments about this notice to the Department within 30 days of publication of this notice in the Pennsylvania Bulletin. Comments should be addressed to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Room 515 Health and Welfare Building, Harrisburg, PA 17120.

   Persons with a disability may use the AT&T Relay Services by calling (800) 654-5984 (TTD users) or (800) 654-5988 (Voice users). Persons who require another alternative should contact Thomas Vracarich at (717) 783-2800.


   Fiscal Note: 14-NOT-151. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 97-1364. Filed for public inspection August 22, 1997, 9:00 a.m.]

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