(a) If a Medicaid recipient is eligible for Medicare coverage (a dual eligible), the Health and Human Services Commission (HHSC) or its designee pays the recipient's Medicare deductible and coinsurance as specified in this section. Payment of deductible and coinsurance is subject to the reimbursement limitations of the Texas Medical Assistance Program (Medicaid).
  (1) For qualified Medicare beneficiaries as defined in the Social Security Act, §1905(p), HHSC or its designee pays on valid Medicare claims the recipient's Part A and Part B deductible and coinsurance as specified in this section. Payments for benefits for individuals eligible for Medicaid only as qualified Medicare beneficiaries are limited to payments for Medicare deductible and coinsurance as described in subsection (b) of this section. Physicians must accept Medicare assignment for Medicaid payment of Part B deductible and coinsurance.
  (2) For Medicaid recipients who are not qualified Medicare beneficiaries, but for whom HHSC otherwise has Part A and Part B deductible or coinsurance liabilities, HHSC or its designee pays the recipient's Part B deductible on valid, assigned Medicare claims. Payment of the recipient's Part B coinsurance and Part A deductible and coinsurance on valid, assigned Medicare claims is limited to claims for services that:
    (A) are within the amount, duration, and scope of Medicaid; and
    (B) would be covered by Medicaid, when the services are provided, if Medicare did not exist.
(b) Except as otherwise specified in subsections (c) and (d) of this section, the payment of the Medicare Part A, Part B, or Part C (for Medicare health plans not contracted with HHSC) deductible and coinsurance is based on the following.
  (1) If the Medicare payment amount equals or exceeds the Medicaid payment rate, HHSC does not pay the Medicare deductible and coinsurance on a crossover claim.
  (2) If the Medicare payment amount is less than the Medicaid payment rate, HHSC pays the Medicare deductible and coinsurance on a crossover claim, but the amount of payment is limited to the lesser of the deductible and coinsurance or the amount remaining after the Medicare payment amount is subtracted from the Medicaid payment rate.
(c) HHSC enters into state agreements with Part C Medicare Advantage Plans whereby HHSC will pay the plans a monthly capitated payment. In exchange, the plans will pay health care providers the Medicare cost sharing obligations attributable to dual eligible members. A health care provider who provides services to a dual eligible member enrolled into a Medicare Advantage Plan with a state agreement must seek payment for the member's Medicare deductible and coinsurance from the participating plan. The health care provider must not seek payment for the member's Medicare deductible and coinsurance from HHSC.
(d) If HHSC has determined that higher payment for a Medicaid service is necessary to ensure adequate access to care or is more cost-effective to the state, HHSC may pay the Medicare deductible and coinsurance on a crossover claim at a higher amount than specified in subsection (b) of this section, not to exceed the greater of the deductible and coinsurance or the amount remaining after the Medicare payment amount is subtracted from the Medicaid payment rate for services. HHSC may do so only where the higher payment has been approved by the Centers for Medicare and Medicaid Services, as specified in the Medicaid State Plan.
(e) Coverage of a recipient's deductible and coinsurance as specified in this section satisfies HHSC's or its designee's obligation to provide coverage for services that would have been paid in the absence of Medicare coverage.

Source Note: The provisions of this §354.1143 adopted to be effective January 1, 1989, 14 TexReg 697; amended to be effective April 1, 1990, 15 TexReg 1840; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 1, 1998, 23 TexReg 8682; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective January 1, 2012, 36 TexReg 9282; amended to be effective July 1, 2012, 37 TexReg 4575