The Medicaid extensions during the pandemic holds individuals in Medicaid even if they’ve lost eligibility or their original certification period has expired. In some cases, this has created an overlap in coverage because some consumers, receiving their manual Medicaid redetermination notices before Maryland Health Connection (MHC) began holding case closure transactions from Maintenance Management Information System (MMIS). They were determined a Qualified Health Plan (QHP) eligible and enrolled in a private health plan without knowing their Medicaid coverage was extended and still active.
Consumer Assistance Workers have raised important questions regarding this overlap in coverage:
1. How does having dual coverage impact claims?
When an individual has coverage from two different carriers, whether private or government, or both, Medicaid is always considered the “payer of last resort.” Through a process called coordination of benefits, the provider should first submit claims to the private health carrier. Any balance not paid by the private health carrier should then be submitted to Medicaid for additional reimbursement. The provider would have to accept Medicaid and apply for reimbursement through “fee for service” avenues.
2. What impact might this have on 1095 forms?
Note: usually Medicaid eligibility precludes eligibility for premium tax credits and could create a potential tax credit clawback for consumers when they file their return for the 2020 tax year?
Maryland Health Benefit Exchange (MHBE) plans to generate 1095A forms for the months in which the consumer received Advanced Premium Tax Credit (APTC), and 1095B forms for the remaining months of Medicaid coverage. In this way, the consumer’s eligibility for Medicaid will not show in the months in which they were also determined eligible for a QHP through the marketplace, removing risk of clawback of tax credits during months of continued Medicaid eligibility.
MHC will provide additional 1095 form information in January of 2021 as it prepares those to deliver those forms.
Any questions, please feel free to contact Director of Consumer Assistance, firstname.lastname@example.org