Notification of Eligibility Workaround for Some Members with Medicare and MassHealth During the Public Health Emergency

Notification of Eligibility Workaround for Some Members with Medicare and MassHealth During the Public Health Emergency

During the public health emergency, you may have provided services to an individual with both Medicare and MassHealth and received a claim’s denial for the portion of the claim submitted to MassHealth for payment. Due to the Medicaid continuous coverage requirement in effect during the COVID-19 public health emergency, MassHealth is generally keeping individuals in the benefit they had on or after March 18, 2020, despite such individuals being potentially eligible for a different coverage type due to age and Medicare status. The benefit they remain in may not be one that is designed to coordinate as a secondary payer and may therefore result in the unintended denial of crossover claims.

To address this issue, MassHealth recently implemented a temporary resolution that will allow for the payment of such crossover claims when submitted for a Medicaid-covered service and the individual is otherwise eligible. Additionally, this resolution has been made retroactive to coincide with the member’s Medicare eligibility start date or March 18, 2020, whichever is later. As such, MassHealth is preparing to reprocess claim denials that may have occurred as a result. These claims will be paid by MassHealth if the member is eligible. Additional details regarding the reprocessing of claims will be posted in the near future.