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Do not bill dually eligible members
March 21, 2024

This article is for providers who care for our Medicare Advantage members

People who are enrolled in both Medicare and Medicaid—often called “dual eligibles”—meet Medicaid financial eligibility rules and also qualify for Medicare due to age, chronic illness, physical disability, mental health problems, or developmental disability.

Dual eligibles may receive assistance with Medicare cost-sharing from a State Medicaid program like MassHealth.

According to CMS rules, you cannot refuse to serve our Medicare Advantage members who are dually eligible. Here is some important information about billing when you provide services to dually eligible members.

If you participate in our Medicare Advantage network and Then when you provide services to dually eligible members
Accept Medicaid You must:
  • Bill us as primary payer.
  • Bill Medicaid—and not the member—for any remaining balance.
  • Accept the Medicaid payment as payment in full.
Do not accept Medicaid You can collect deductible, co-insurance, or copayment amounts only if you notify the member and have them sign a non-covered service waiver form on the date of service* before you render services.

*This ensures that the member understands that the form, a contract, allows you to collect fees for cost sharing.

Thank you

As always, thank you for the care you provide to your patients—our members.