CMS-179 Attachment 4.19 B, Supplement 1

Form Approved CMS-179
OMB No. 0938-0193
Revision:
Supplement 1 to
ATTACHMENT 4.19-B
Page 1
OMB No.:0938STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:__________________
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
Payment of Medicare Part A and Part B Deductible/Coinsurance
Except for a nominal recipient co-payment (as specified in Attachment 4.18 of this State
plan), if applicable, the Medicaid agency uses the general method for payment specified
in the chart on page 2 of this supplement. Codes appearing in the chart have the
meanings defined below:
1.

SP: Payments are limited to State plan rates and payment methodologies.
For specific Medicare services which are not otherwise covered by this State plan,
the Medicaid agency uses Medicare payment rates unless a special rate or method
is set out on Page 3, section A of this supplement.

2.

MR: Payments are up to the full amount of the Medicare rate.

3.

NR: Payments are up to the amount of a special rate, or according to a special
method, described on Page 3 in item __ of this attachment, for those groups and
payments listed below and designated with the letters "NR".

4.

Any exceptions to the general methods used for a particular group or payment are
specified on Page 3, section B and Pages 3a & 3b of this supplement.

______________________________________________________________________________
TN: ______
Approval Date
___
Effective Date ______
Supersedes TN:_____
Revision:
Supplement 1 to
ATTACHMENT 4.19-B
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:__________________
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
Payment of Medicare Part A and Part B Deductible/Coinsurance

Group

Part A
Deductible

Part A
Coinsurance

Part B
Deductible

Part B
Coinsurance

QMB1
QMB Plus2
FBDE3
1. QMB: Qualified Medicare Beneficiary. A QMB is eligible for payment of all Medicare
Part A and Part B deductibles and co-insurance, including those charged through a
Medicare Part C plan. For QMB an entry must be made in each column.
2. QMB Plus: QMB Plus full Medicaid. A QMB Plus is eligible for payment of all
Medicare Part A and Part B deductibles and co-insurance, including those charged
through a Medicare Part C plan, as well as all benefits available to a fully eligible
Medicaid recipient under the State plan. For QMB Plus an entry must be made in each
column.
3. FBDE: Full Benefit Dual Eligible. A Medicare beneficiary who is eligible for Medicaid
under the State plan but who does not meet income, resource or other criteria for
eligibility as a QMB. States are liable only for services covered under the State plan and
rendered by a provider enrolled in the State Medicaid program. Payment must be
calculated based on the rate indicated above, less the Medicare payment liability and any
other third party liability.

TN: ______
Supersedes TN:_____

Approval Date

___

Effective Date ______

Revision:
Supplement 1 to
ATTACHMENT 4.19-B
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:__________________
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
Payment of Medicare Part A and Part B Deductible/Coinsurance

Section A. If SP is entered on Page 2, specify the special rate or methodology
used as the basis of payment for Medicare services which are not otherwise
covered by this State plan, if the State is not using the Medicare rate for those
services.
Section B. Specify any exceptions to the rates indicated on Page 2 for particular
groups or payment types.

TN: ______
Supersedes TN:_____

Approval Date

___

Effective Date ______

Revision:
Supplement 1 to
ATTACHMENT 4.19-B
Page 3a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State: ________________
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
MEDICAID OBLIGATIONS FOR COST-SHARING IN MEDICARE PART C PLANS

____ The State opts to make capitated payments (per member per month-pmpm) for dual
eligibles enrolled in Medicare Part C plans.
1. Part A and Part B Cost Sharing
A. Groups Capitated. The State makes pmpm payments for Medicare Part A and Part B
cost sharing for the following individuals (as described on page 2 of this supplement)
enrolled in a Medicare Part C plan:
____ QMB
____ QMB Plus
____ Full Benefit Dual Eligibles
B. Payment Methodology. Describe the payment methodology the State uses to
determine pmpm payment amounts. This rate can be the actuarial equivalent of the
Part A and Part B deductibles and coinsurance in fee-for-service Medicare. The
baseline can also be built on pmpm payments to Medicaid Managed Care
Organizations for a like population, and/or can be experience rated for factors such as
age, disability, diagnosis, etc. Factors employed to arrive at the pmpm amounts and
the method and timing of rate increases must be specified.

TN: ______
Supersedes TN:_____
Revision:

Approval Date

___

Effective Date ______

Supplement 1 to
ATTACHMENT 4.19-B
Page 3b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State: ________________
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
MEDICAID OBLIGATIONS FOR COST-SHARING IN MEDICARE PART C PLANS
____________________________________________________________________________
2. Optional Supplemental Benefits or enrollment in a Special Needs Plan (SNP)
A. Groups enrolled. The State opts to make payments for optional supplemental benefits
for the following individuals (as described on page 2 of this supplement) enrolled in a
Medicare Part C plan or SNP:
____ QMB Plus
____ Full Benefit Dual Eligibles
B. Methodology. Describe the payment methodology used to determine the pmpm
payment amount for cost sharing for optional supplemental benefits or enrollment in a
SNP.

TN: ______
Supersedes TN:_____

Approval Date

___

Effective Date ______

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB number for this information collection is 0938-0193 (Expires: TBD). The time required to complete this information collection is estimated to
average 1 hour per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn:
PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21224-1850.