WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

WHEN YOU HAVE MEDICAID

AND OTHER INSURANCE

Balance Billing, Choosing Providers

and Other Advice on Third Party Liability (TPL)

A guide to understanding health coverage in New Jersey

if you have Medicaid and Medicare and/or Other Health Insurance.

Prepared by DHS Office of Publications (revised 1/16)

TABLE OF CONTENTS

Introduction ................................................................................................1

Health Plan contact information ........................................................1

When you have Medicare and Medicaid .............................................. 2-8

Choosing Providers ..........................................................................2

Health Insurance Cards ....................................................................2

Balance Billing .............................................................................. 2-3

Coverage Responsibility ...................................................................4

Referrals ...........................................................................................5

Medicare and Medicaid Reference Chart ..................................... 6-8

When you have Other Health Insurance and Medicaid .................... 9-15

Choosing Providers ......................................................................…9

Health Insurance Cards ....................................................................9

Balance Billing .......................................................................... 10-11

Coverage Responsibility .................................................................12

Referrals .........................................................................................13

Other Health Insurance and Medicaid Reference Chart ........... 14-15

When you have Other Health Insurance, Medicare

and Medicaid ...................................................................................... 16-19

Choosing Providers ........................................................................16

Health Insurance Cards ..................................................................17

Balance Billing ................................................................................17

Coverage Responsibility .................................................................18

Referrals .........................................................................................19

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

INTRODUCTION

If you have Medicaid and other health insurance coverage, each type of coverage is

called a “payer.” When there is more than one payer, there are rules that decide how

payments are coordinated and how much each payer pays for each service. In some

cases, a member may have only one payer, Medicaid. In some cases, a member may

have a second or third payer, which may include but not be limited to Medicare, or other

health insurance.

Many members have other health insurance or Medicare as their primary payer, as well as

Medicaid Fee-for-Service (FFS) as their secondary or tertiary payer. This includes people

who belong to a Medicare Advantage (MA) Health Plan

as their primary insurance.

In New Jersey, Medicaid Health Plans are replacing Medicaid FFS as the secondary (or

tertiary) payer. When you enroll in a Medicaid Health Plan, MEDICAID IS GENERALLY

THE PAYER OF LAST RESORT. This means that Medicare and/or your other health

insurance pay for covered services first, and your Medicaid Health Plan generally pays

for covered services last.

YOU CAN NEVER BE DENIED MEDICALLY NECESSARY COVERED SERVICES

BECAUSE OF ISSUES OR CONFUSION WITH MULTIPLE PAYERS.

If you receive a bill for any services, you should contact your Medicaid Health Plan member

services department right away:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

When You Have Medicaid And Other Insurance is meant to assist Medicaid Health Plan

members and families in understanding the details with service payments. If you need

assistance understanding some of the information, please share this guide with a family

member, friend, and healthcare provider or call your Medicaid Health Plan with any

questions.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

Examples of other health insurance: employee health insurance, automobile insurance, Veteran’s

benefits

Medicare Advantage is a Medicare Health Plan which includes benefits covered under Medicare Parts

A and B, and may include Medicare Part D and additional benefits.

WHEN YOU HAVE MEDICARE AND MEDICAID

CHOOSING PROVIDERS

You may continue to see your Medicare providers for Medicare covered services, even

when those providers are not in the Medicaid Health Plan provider network. TO ENSURE

THAT YOU WILL NOT BE BILLED, YOU MAY WANT TO CHOOSE MEDICARE

PROVIDERS THAT ARE ALSO IN YOUR MEDICAID HEALTH PLAN PROVIDER

NETWORK.

There are some services which are covered by your Medicaid Health Plan, but not by

Medicare. For example, dental services, vision services, hearing aids and incontinence

supplies are covered by your Medicaid Health Plan, but not by Medicare. YOU SHOULD

ONLY USE MEDICAID HEALTH PLAN PROVIDERS FOR THESE SERVICES/

SUPPLIES. MEDICAID HEALTH PLAN PROVIDERS ARE PROHIBITED FROM

BILLING YOU FOR MEDICAID COVERED SERVICES.

Please note: Medicare providers who do not participate with Medicaid have the right not to

accept you as a patient. You must find Medicare providers who are willing to treat patients

who have Medicare and Medicaid.

HEALTH INSURANCE CARDS

When you enroll in a Medicaid Health Plan, you will receive a Medicaid Health Plan

identification (ID) card. All Medicaid Health Plan ID cards will list a Medicaid Health Plan

primary care provider (PCP). YOU SHOULD CONTINUE TO SEE YOUR MEDICARE

PCP, REGARDLESS OF THE INFORMATION ON THE MEDICAID HEALTH PLAN ID

CARD. You are only required to see your Medicaid Health Plan PCP when the needed

service is not covered by Medicare, but is covered by your Medicaid Health Plan.

If you have Medicare and Medicaid, you should show all health insurance cards any time

you visit a doctor, hospital, pharmacy, lab or other service provider. This will ensure that

all providers know how to bill for that particular service, supply or prescription.

BALANCE BILLING

All providers who accept Medicare and Medicaid cannot bill individuals who have dual

coverage (both Medicare and Medicaid) for the balance of a bill. Individuals with dual

coverage are protected from being billed for the balance due on a medical claim for

medically necessary, covered services. If a provider does not know you have Medicaid,

they may send you a bill to pay the balance of the claim in error. Therefore, always

present your Medicare, Medicaid Health Plan, and plastic Medicaid Health Benefits

Identification (HBID) cards when you check in for a medical visit.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

The medical office, hospital or pharmacy will need to know all of the health insurance

coverage you have to know how to submit the claim for payment.

Here are examples of how a Medicare and Medicaid provider should handle the balance

on a medical bill when you have Medicare and Medicaid:

For an office visit:

If the charge for a service is $80.00 and the Medicare payment is $64.00 (80%

of the charge), your Medicaid Health Plan will pay the 20% co-insurance or the

difference between the Medicare reimbursement and the Medicaid Health Plan

rate, whichever is less. In this example, let’s say the Medicaid Health Plan

reimbursement rate for the service is $70.00. In that case, the Medicaid Health

Plan would pay $6.00 toward the bill (The difference between the $70.00 Medicaid

Health Plan rate and the amount Medicare paid $64.00 = $6.00). You are not

responsible for any additional payment. If the Medicaid Health Plan rate is

lower than the Medicare 80% payment, no payment is made to the Medicare/

Medicaid provider. As long as you have informed the Medicare/Medicaid

provider of your Medicaid Health Plan status, the doctor will know that you

are not responsible for a co-insurance payment.

For a hospital stay:

If the charge for a hospital stay is $500.00

and the Medicare payment is $400.00 (80%

of the charge), your Medicaid Health Plan will

pay the 20% co-insurance or the difference

between the Medicare reimbursement and the

Medicaid Health Plan rate, whichever is less.

In this example, let’s say the Medicaid Health

Plan reimbursement rate for the hospital stay

is $350.00. In that case, the Medicaid Health

Plan would pay $0.00 toward the bill (The

cost of the hospital stay exceeds the Medicaid

Health Plan rate). You are not responsible

for any additional payment. As long as

you have informed the Medicare/Medicaid

provider of your Medicaid Health Plan

status, the hospital/doctor will know you

are not responsible for a co-insurance

payment.

FOR ALL SCENARIOS, MEDICAID HEALTH PLANS WILL FOLLOW THE SAME

PAYMENT RULES THAT MEDICAID FFS DID IN DETERMINING THE PAYMENT OF

THE CO-INSURANCE AMOUNT.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

COVERAGE RESPONSIBILITY

Based on a regulation that has been in effect since January 2006, you can be billed for

services rendered by a provider if the following criteria exist:

1 – You have been paid for the service by a health insurance company or other

third party and you have failed or refused to remit to the provider that portion of the

third party’s payment to which the provider is entitled by law.

You may also be billed for services if the following criteria exist:

1 – Either:

A – The service is not covered by any of your payers; OR

B – The service is determined to be medically unnecessary before it is

rendered; OR

C – The provider does not participate with the Medicaid Health Plan, either

generally or for that service;

AND

2 – You are informed in writing before the service is rendered that either A, B or C

above exists and you voluntarily agree in writing before the service is rendered to

pay for all or part of the provider’s charges; AND

3 – The service is not an emergency service as defined in State and federal law;

AND

4 – The service is not a trauma service as defined by State law; AND

5 – The additional protections under federal and State law

do not apply; AND

6 – The provider has received no program payment from either Medicaid FFS or

your Medicaid Health Plan.

Example:

If you have Medicare and Medicaid and receive a cosmetic surgery from a Medicare

provider who is also in your Medicaid Health Plan provider network, this service will

not be paid for by Medicare or your Medicaid Health Plan. Cosmetic surgeries are

not covered by Medicare or your Medicaid Health Plan. However, the service must

meet the criteria listed above and you must agree in writing to pay for the service

prior to the service being rendered.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

Adapted from N.J.A.C. 10:74-8.7

42 U.S.C. § 1396u-2(b)(6), 42 CFR 438.106, N.J.A.C. 11:24-9.1(d)9 and/or 15.2(b)7ii

REFERRALS

WHEN YOUR MEDICARE PCP REFERS YOU TO SEE A MEDICARE SPECIALIST FOR

A MEDICARE–ONLY COVERED SERVICE OR FOR A MEDICARE AND MEDICAID

HEALTH PLAN COVERED SERVICE, YOU DO NOT NEED TO OBTAIN A REFERRAL

FROM YOUR MEDICAID HEALTH PLAN PCP. The same billing standards apply and

you cannot be billed for a Medicare only or for a Medicare and Medicaid Health Plan

covered service, when that service is received from a Medicare provider.

However, if you need health services that are not covered by Medicare, you may need a

referral from your Medicaid Health Plan PCP. These are examples of services that are not

covered by Medicare, but are covered by your Medicaid Health Plan: hearing aids, vision

exams, incontinence supplies, and personal care assistance services.

Each Medicaid Health Plan has established different guidelines regarding referrals to see

specialists within the Medicaid Health Plan network. Please contact your Medicaid Health

Plan for more information:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

REMEMBER:

YOU CAN NEVER BE DENIED MEDICALLY NECESSARY COVERED SERVICES

BECAUSE OF ISSUES OR CONFUSION WITH MULTIPLE PAYERS.

If you receive a bill for any services, you should contact your Medicaid Health Plan member

services department right away:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

IF SERVICE IS

An approved, Medicare

covered benefit

(Examples: outpatient

hospital service, primary

care, specialists,

lab tests, radiology)

Inpatient hospital care

Emergency care received

at a hospital emergency

department

A medically necessary

service which is not

covered by Medicare

but is covered by your

Medicaid Health Plan

(Examples: dental

services, hearing aids,

personal care assistant

services, medical day care

services, incontinence

supplies, family planning

services)

THEN

Medicare is the primary

payer and Medicaid

Health Plan is the

secondary payer.

Medicare is the primary

payer and Medicaid

Health Plan is the

secondary payer.

Medicare is the primary

payer and Medicaid

Health Plan is the

secondary payer.

Medicaid Health Plan is

the only payer.

PROVIDER GUIDANCE

Use a Medicare provider

who does not need to be

in your Medicaid Health

Plan’s provider network.

Use a hospital that is

affiliated with Medicare. If

possible, use a hospital

that is also in your

Medicaid Health Plan

provider network.

Go to the nearest hospital.

Use a provider in your

Medicaid Health Plan

provider network.

WHEN YOU HAVE BOTH MEDICARE AND MEDICAID

If you have both Medicare and Medicaid, you should always choose providers in

your Medicare provider network for Medicare covered, medically necessary services.

When receiving Medicare covered services, all Medicare guidelines must be followed

to ensure Medicare coverage. See http://www.medicare.gov for more information.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

A provider who has opted out of Medicare is one that does not accept Medicare beneficiaries for any

services.

Generally, when a service is rendered by a provider who has opted out of Medicare, and is not in your

Medicaid Health Plan network, the service will not be covered by Medicare or your Medicaid Health Plan.

Medicare Advantage is a Medicare Health Plan which includes benefits covered under Medicare Parts A

and B, and may include Medicare Part D and additional benefits.

Creditable drug coverage is coverage from an employer or union plan in place of Medicare Part D.

Exceptions: benzodiazepines, barbiturates, smoking cessation drugs, and certain vitamins are not

covered by Medicare Part D but are covered by your Medicaid Health Plan. Co-pays do not apply.

IF SERVICE IS

Rendered by a provider

who has opted out of

Medicare for Medicare

Parts A and B members

and is not in your

Medicaid Health Plan

provider network

Rendered to a Medicare

Advantage Health

Plan

member by an

unapproved, uncovered

out-of-network provider

A prescription drug

covered under Medicare

Part D

A prescription drug not

covered under Medicare

Part D or creditable drug

coverage

THEN

Member is responsible

for payment if properly

informed and signed

private contract.

Member is responsible for

payment.

Medicare is the primary

payer. Member must pay

a small prescription co-

pay, if applicable.

Member is responsible

for payment.

Some

exceptions apply. See

footnote at the bottom of

this page.

PROVIDER GUIDANCE

To avoid being

responsible for medical

bills, be sure to use

providers who participate

in Medicare.

To avoid being responsible

for medical bills, be sure to

use providers who are in

the Medicare Advantage

Health Plan’s provider

network.

Use a Medicare

participating pharmacy to

receive prescription drugs.

N/A

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

IF SERVICE IS

For nursing facility care,

including short-term in-

patient rehabilitation

settings

THEN

Medicare and Medicaid

cover some days in a

nursing facility. For more

information, contact

SHIP at 1-800-792-8820

(TTY 711), Medicare at

1-800-MEDICARE (1-

800-633-4227) (TTY

1-877-486-2048) or

your Medicaid Health

Plan member services

department.

PROVIDER GUIDANCE

Contact the State Health

Insurance Assistance

Program (SHIP) at

1-800-792-8820 (TTY

711), Medicare at

1-800-MEDICARE (1-

800-633-4227) (TTY

1-877-486-2048) or

your Medicaid Health

Plan member services

department for guidance.

WHEN YOU HAVE OTHER HEALTH INSURANCE AND MEDICAID

CHOOSING PROVIDERS

You should always choose providers in your other health insurance provider network for

services covered by your other health insurance. You may continue to see your other

health insurance provider, even when those providers are not in your Medicaid Health

Plan provider network. When possible, if you are choosing new providers, you may want

to choose providers that are in your other health insurance provider network and also

in your Medicaid Health Plan provider network. GENERALLY, WHEN YOU CHOOSE

PROVIDERS IN BOTH NETWORKS FOR MEDICAID HEALTH PLAN COVERED

SERVICES, YOU CANNOT BE BILLED.

Under limited circumstances, you may be responsible for a portion of the payment. See

pages 10-11 for details and billing examples.

There are some services which are covered by your Medicaid Health Plan, but may not be

covered by your other health insurance. For example, private duty nursing, personal care

assistance and incontinence supplies are covered by your Medicaid Health Plan, but may

not be covered by your other health insurance. WHEN YOU USE MEDICAID HEALTH

PLAN PROVIDERS FOR THESE SERVICES/SUPPLIES, YOU CANNOT BE BILLED

FOR THE BALANCE.

HEALTH INSURANCE CARDS

When you enroll in a Medicaid Health Plan, you will receive a Medicaid Health Plan

identification (ID) card. All Medicaid Health Plan ID cards will list a Medicaid Health

Plan primary care provider (PCP). YOU SHOULD CONTINUE TO SEE YOUR OTHER

HEALTH INSURANCE PCP, REGARDLESS OF THE INFORMATION ON THE

MEDICAID HEALTH PLAN ID CARD, EVEN WHEN THE OTHER HEALTH INSURANCE

PCP DOES NOT PARTICIPATE WITH THE MEDICAID HEALTH PLAN. You are only

required to see your Medicaid Health Plan PCP when the needed service is not covered

by your other health insurance, but is covered by your Medicaid Health Plan.

If you have other health insurance and Medicaid, we recommend you show all health

insurance cards anytime you visit a doctor, hospital, pharmacy, lab or other service

provider. However, if you have other health insurance and Medicaid, AND YOU CHOOSE

NOT TO SHOW A PROVIDER YOUR MEDICAID HEALTH PLAN ID CARD, YOU MAY

BE HELD RESPONSIBLE FOR ANY APPLICABLE CO-INSURANCE PAYMENTS FOR

THE SERVICE RENDERED. By showing both cards, you should not be responsible for

any payments; however under limited circumstances, you may be responsible for a portion

of the payment. See pages 10-11 for details and billing examples.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

BALANCE BILLING

Providers who are in your other health insurance provider network and your Medicaid

Health Plan provider network are prohibited from billing individuals for the balance of a bill

for Medicaid Health Plan covered services. In order to prevent being billed for Medicaid

Health Plan covered services, providers in your other health insurance network who are

not in your Medicaid Health Plan network must be informed of your Medicaid status.

Individuals on Medicaid are protected from being billed for the balance due on a medical

claim for medically necessary, covered services. If a provider does not know you have

Medicaid, they may send you a bill to pay the balance of the claim in error. Therefore,

always present your Other Health Insurance, Medicaid Health Plan, and plastic

Medicaid HBID cards when you check in for a medical visit. The medical office, hospital

or pharmacy will need to know all of the health insurance coverage you have to know how

to submit the claim for payment.

After an other health insurance provider bills your other health insurance and receives

payment, they will submit a claim for the unpaid balance to your Medicaid Health Plan. In

the past, if the provider was not also a Medicaid provider, they may have been unable to bill

Medicaid because they were not set up in the Medicaid FFS claims system. The Medicaid

Health Plan can process claims of providers who are not in their provider network.

At the same time, Medicaid Health Plans cannot exceed the maximum reimbursement that

the Medicaid Health Plan would have covered if it had been the primary payer.

Children under agreement with the

Department of Children and Families/

Division of Youth and Family Services

(DCF/DYFS) who have other health

insurance and Medicaid do not pay

any co-insurance.

Here are examples of how a provider

should handle the balance on a

medical bill when you have other

health insurance and Medicaid:

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

For an office visit:

If the charge for a service is $80.00 and the other health insurance payment

is $64.00 (80% of the charge), your Medicaid Health Plan will pay the 20% co-

insurance or the difference between the other health insurance reimbursement

and the Medicaid Health Plan rate, whichever is less. In this example, let’s say

the Medicaid Health Plan rate for the service is $70.00. In that case, the Medicaid

Health Plan would pay $6.00 toward the bill (The difference between the $70.00

Medicaid Health Plan rate and the amount your other health insurance paid $64.00

= $6.00). Generally, if the provider is in your other health insurance network

AND your Medicaid Health Plan network, you are not responsible for any

additional payment. If the provider is in your other health insurance network,

but NOT your Medicaid Health Plan network, you may be responsible for

a portion of payment. If the Medicaid Health Plan rate is lower than the other

health insurance 80% payment, no payment is made to the other health insurance

provider. If the provider is in your other health insurance network AND your

Medicaid Health Plan network, you are not responsible for any additional

payment. If the provider is in your other health insurance network, but NOT

your Medicaid Health Plan network, you may be responsible for a portion of

payment.

For a hospital stay:

If the charge for a hospital stay is $500.00 and the other health insurance payment

is $400.00 (80% of the charge), your Medicaid Health Plan will pay the 20% co-

insurance or the difference between the other health insurance reimbursement

and the Medicaid Health Plan rate, whichever is less. In this example, let’s say

the Medicaid Health Plan rate for the hospital stay is $350.00. In that case, the

Medicaid Health Plan would pay $0.00 toward the bill (The cost of the hospital stay

exceeds the Medicaid Health Plan rate). Generally, if the provider is in your

other health insurance network AND your Medicaid Health Plan network, you

are not responsible for any additional payment. If the provider is in your

other health insurance network, but NOT your Medicaid Health Plan network,

you may be responsible for a portion of payment.

FOR ALL SCENARIOS, MEDICAID HEALTH PLANS WILL FOLLOW THE SAME

PAYMENT RULES THAT MEDICAID FFS DID IN DETERMINING THE PAYMENT OF

THE CO-INSURANCE AMOUNT.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

COVERAGE RESPONSIBILITY

Based on a regulation that has been in effect since January 2006, you can be billed for

services rendered by a provider if the following criteria exist:

1 – You have been paid for the service by a health insurance company or other

third party and you have failed or refused to remit to the provider that portion of the

third party’s payment to which the provider is entitled by law.

You may also be billed for services if the following criteria exist:

1 – Either:

A – The service is not covered by any of your payers; OR

B – The service is determined to be medically unnecessary before it is

rendered; OR

C – The provider does not participate with the Medicaid Health Plan, either

generally or for that service;

AND

2 – You are informed in writing before the service is rendered that either A, B or C

above exists and you voluntarily agree in writing before the service is rendered to

pay for all or part of the provider’s charges; AND

3 – The service is not an emergency service as defined in State and federal law;

AND

4 – The service is not a trauma service as defined by State law; AND

5 – The additional protections under federal and State law

do not apply; AND

6 – The provider has received no program payment from either Medicaid FFS or

your Medicaid Health Plan.

Example:

If you have other health insurance and Medicaid and receive medically necessary

knee replacement surgery by a provider in your other health insurance provider

network, and the service is covered by your other health insurance, your other

health insurance will be the primary payer for the surgery and the inpatient hospital

stay. Your Medicaid Health Plan will pay the difference for any Medicaid covered

services received during the surgery and inpatient hospital stay, provided that the

total reimbursement does not exceed the pre-determined Medicaid Health Plan

rate for that/those service(s).

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

Adapted from N.J.A.C. 10:74-8.7

42 U.S.C. § 1396u-2(b)(6), 42 CFR 438.106, N.J.A.C. 11:24-9.1(d)9 and/or 15.2(b)7ii

REFERRALS

WHEN YOUR OTHER HEALTH INSURANCE PCP REFERS YOU TO SEE AN OTHER

HEALTH INSURANCE SPECIALIST FOR AN OTHER HEALTH INSURANCE-ONLY

SERVICE OR FOR AN OTHER HEALTH INSURANCE AND MEDICAID HEALTH PLAN

COVERED SERVICE, YOU DO NOT NEED A REFERRAL FROM YOUR MEDICAID

HEALTH PLAN PCP. The same billing standards apply and you can only be billed for

services when the service meets the criteria discussed in the sections on Balance Billing

(pages 10-11) and Coverage Responsibility (page 12).

However, if you need health services that are not covered by your other health insurance,

you may need a referral from your Medicaid Health Plan PCP. These are examples of

services that may not be covered by your other health insurance, but are covered by your

Medicaid Health Plan: incontinence supplies, private duty nursing, medical day care and

personal care assistance services.

Each Medicaid Health Plan has established different guidelines regarding referrals to see

specialists within the Medicaid Health Plan network. Please contact your Medicaid Health

Plan for more information:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

REMEMBER:

YOU CAN NEVER BE DENIED MEDICALLY NECESSARY COVERED SERVICES

BECAUSE OF ISSUES OR CONFUSION WITH MULTIPLE PAYERS.

If you receive a bill for any services, you should contact your Medicaid Health Plan member

services department right away:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

IF SERVICE IS

An approved, other

health insurance covered

benefit, including referrals

from your other health

insurance PCP

A medically necessary

service which may not

be covered by other

health insurance but is

covered by your Medicaid

Health Plan (Examples:

incontinence supplies,

personal care assistant

services, medical day care

services, family planning

services)

THEN

Other health insurance

is the primary payer and

Medicaid Health Plan is

the secondary payer. A

Medicaid Health Plan

referral is not required.

Medicaid Health Plan is

the primary payer.

PROVIDER GUIDANCE

Use a provider in your

other health insurance

provider network. Your

Medicaid Health Plan ID

card will have a Medicaid

Health Plan PCP on it.

You should still use your

other health insurance

PCP for all other health

insurance covered

services regardless of the

Medicaid Health Plan PCP

listed on your Medicaid

Health Plan ID card.

Use a provider in your

Medicaid Health Plan

provider network.

WHEN YOU HAVE BOTH OTHER HEALTH INSURANCE AND MEDICAID

If you have both Other Health Insurance and Medicaid, you should always choose

providers in your other health insurance provider network for other health insurance

covered, medically necessary services. If possible, finding providers in both your other

health insurance provider network and your Medicaid Health Plan provider network

should eliminate any chance of being billed for other health insurance and Medicaid

covered services. There are many different types of other health insurance and each

type of other health insurance will have different guidelines and types of coverage.

Refer to your other health insurance member materials for more information. Generally,

when your other health insurance covers a Medicaid Health Plan covered service, your

Medicaid Health Plan will also cover the service, provided the service does not exceed

the Medicaid Health Plan reimbursement rate for that service. See Balance Billing on

pages 10-11 for more information.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

IF SERVICE IS

Rendered by a provider that

is not in your other health

insurance provider network

and is not in your Medicaid

Health Plan provider network

and was not authorized by

your other health insurance

A prescription drug covered

by your other health

insurance

A prescription drug not

covered by your other health

insurance, but covered by

your Medicaid Health Plan

A prescription drug not

covered by your other health

insurance or your Medicaid

Health Plan.

An inpatient stay in an

other health insurance

provider hospital

Emergency care received

at a hospital emergency

department

For nursing facility care

THEN

Member is responsible

for payment.

Other health insurance is

primary payer. Medicaid

Health Plan is secondary

payer and covers the drug

co-pay.

Medicaid Health Plan

is only payer.

Member is responsible

for payment.

Other health insurance is

the primary payer. Medicaid

Health Plan is the

secondary payer.

Other health insurance is the

primary payer and Medicaid

Health Plan is the

secondary payer.

Other health insurance

and your Medicaid Health

Plan may both cover

nursing facility care. For

more information about

payments, contact your

other health insurance

service representative

or your Medicaid Health

Plan member services

department.

PROVIDER GUIDANCE

To avoid being responsible

for medical bills, be sure to

use providers who are in

your other health insurance’s

provider network.

Use an other health

insurance participating

pharmacy to receive

prescription drugs.

Use a pharmacy in your

Medicaid Health Plan

provider network.

N/A

Use a hospital that is in

your other health insurance

provider network. If

possible, use a hospital

that is also in your Medicaid

Health Plan provider network

Go to the nearest hospital.

Use a facility that is in your

other health insurance

and Medicaid Health Plan

provider networks.

WHEN YOU HAVE OTHER HEALTH INSURANCE,

MEDICARE AND MEDICAID

CHOOSING PROVIDERS

When you have other health insurance, Medicare and Medicaid, either your other

health insurance or Medicare is the primary payer for most covered services. To

determine which health coverage is your primary payer, please use the following resources:

1) Call Medicare’s State Health Insurance Assistance Program (SHIP) at

1-800-792-8820 (TTY 711)

2) Call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048)

3) The Medicare Guide to Who Pays First:

http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf

You should always choose providers from your primary provider network for services

covered by your primary health coverage. When possible, it is recommended that you

choose providers that are in your other health insurance provider network that are also

Medicare providers. WHEN YOU CHOOSE PROVIDERS IN BOTH NETWORKS FOR

MEDICAID HEALTH PLAN COVERED SERVICES, YOU CANNOT BE BILLED.

There are some services which are covered by your Medicaid Health Plan, but may not

be covered by your other health insurance or Medicare. For example, dental services,

personal care assistance services, medical day care and incontinence supplies are

covered by your Medicaid Health Plan, but may not be covered by your other health

insurance or Medicare. WHEN YOU USE MEDICAID HEALTH PLAN PROVIDERS FOR

THESE SERVICES/SUPPLIES, YOU CANNOT BE BILLED FOR THE BALANCE.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

HEALTH INSURANCE CARDS

When you enroll in a Medicaid Health Plan, you will receive a Medicaid Health Plan

identification (ID) card. All Medicaid Health Plan ID cards will include a Medicaid Health

Plan primary care provider (PCP). YOU SHOULD CONTINUE TO SEE YOUR OTHER

HEALTH INSURANCE OR MEDICARE PCP, REGARDLESS OF THE INFORMATION

ON THE MEDICAID HEALTH PLAN ID CARD. You are only required to see your

Medicaid Health Plan PCP when the needed service is not covered by your other health

insurance but is covered by your Medicaid Health Plan.

If you have other health insurance, Medicare and Medicaid, we recommend you show all

health insurance cards anytime you visit a doctor, hospital, pharmacy, lab or other service

provider. However, if you have other health insurance, Medicare and Medicaid, you can

choose if you prefer NOT TO SHOW A PROVIDER YOUR MEDICAID HEALTH PLAN ID

CARD, IN WHICH CASE YOU MAY BE HELD RESPONSIBLE FOR ANY APPLICABLE

CO-INSURANCE PAYMENTS FOR THE SERVICE RENDERED. By showing all cards,

you should not be responsible for any payments; however under limited circumstances,

you may be responsible for a portion of the payment. See below for details.

BALANCE BILLING

If you have other health insurance, Medicare and Medicaid, the rules that apply to members

with Medicare and Medicaid apply to you as well. Members with both Medicare and

Medicaid cannot be billed for services rendered by providers that accept Medicare.

It is recommended that you receive services from providers in your other health insurance

network that accept Medicare. For any service which is covered by your other health

insurance, your other health insurance is the primary payer, Medicare is the second payer,

and your Medicaid Health Plan is the last payer. Contact the Medicare Coordination of

Benefits Call Center at 1-800-999-1118 (TTY 1-800-318-8782) to determine if, in your

situation, Medicare or the other health insurance is the primary payer.

FOR ALL SCENARIOS, MEDICAID HEALTH PLANS WILL FOLLOW THE SAME

PAYMENT RULES THAT MEDICAID FFS DID IN DETERMINING THE PAYMENT OF

THE CO-INSURANCE AMOUNT.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

COVERAGE RESPONSIBILITY

Based on a regulation that has been in effect since January 2006, you can be billed for

services rendered by a provider if the following criteria exist:

1 – You have been paid for the service by a health insurance company or other

third party and you have failed or refused to remit to the provider that portion of the

third party’s payment to which the provider is entitled by law.

You may also be billed for services if the following criteria exist:

1 – Either:

A – The service is not covered by any of your payers; OR

B – The service is determined to be medically unnecessary before it is

rendered; OR

C – The provider does not participate with the Medicaid Health Plan, either

generally or for that service;

AND

2 – You are informed in writing before the service is rendered that either A, B or C

above exists and you voluntarily agree in writing before the service is rendered to

pay for all or part of the provider’s charges; AND

3 – The service is not an emergency service as defined in State and federal law;

AND

4 – The service is not a trauma service as defined by State law; AND

5 – The additional protections under federal and State law

do not apply; AND

6 – The provider has received no program payment from either Medicaid FFS or

your Medicaid Health Plan.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

Adapted from N.J.A.C. 10:74-8.7

42 U.S.C. § 1396u-2(b)(6), 42 CFR 438.106, N.J.A.C. 11:24-9.1(d)9 and/or 15.2(b)7ii

REFERRALS

WHEN YOUR OTHER HEALTH INSURANCE OR MEDICARE PCP REFERS YOU

TO SEE AN OTHER HEALTH INSURANCE OR MEDICARE SPECIALIST FOR AN

OTHER HEALTH INSURANCE OR MEDICARE ONLY OR FOR AN OTHER HEALTH

INSURANCE /MEDICARE AND MEDICAID HEALTH PLAN COVERED SERVICE,

YOU DO NOT NEED TO OBTAIN A REFERRAL FROM YOUR MEDICAID HEALTH

PLAN PCP. The same billing standards apply and you generally cannot be billed for an

other health insurance/Medicare and Medicaid Health Plan covered service, when that

service is received from an other health insurance/Medicare provider. Additionally, you

can only be billed for services received from a non other health insurance /Medicare and

non Medicaid Health Plan provider when the service meets the criteria discussed in the

sections on Balance Billing (page 17) and Coverage Responsibility (page 18).

However, if you need health services that are not covered by your other health insurance

or by Medicare, you many need a referral from your Medicaid Health Plan PCP. These

are examples of services that may not be covered by your other health insurance or

Medicare, but are covered by your Medicaid Health Plan: incontinence supplies, private

duty nursing, medical day care and personal care assistance services.

Each Medicaid Health Plan has established different guidelines regarding referrals to see

specialists in the Medicaid Health Plan network. Please contact your Medicaid Health

Plan for more information:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

REMEMBER:

YOU CAN NEVER BE DENIED MEDICALLY NECESSARY COVERED SERVICES

BECAUSE OF ISSUES OR CONFUSION WITH MULTIPLE PAYERS.

If you receive a bill for any services, you should contact your Medicaid Health Plan member

services department right away:

Aetna Better Health 1-855-232-3596 TTY/TDD 711

Amerigroup 1-800-600-4441 TTY/TDD 1-800-855-2880

Horizon NJ Health 1-877-765-4325 TTY/TDD 1-800-654-5505

UnitedHealthcare 1-800-941-4647 TTY/TDD 711

WellCare 1-888-453-2534 TTY/TDD 1-877-247-6272

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

Note: When You Have Medicaid And Other Insurance is not a legal document.

The official Medicaid program provisions are contained in the relevant laws and

regulations. The information in this document is correct as of October 1, 2011.

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE