Choice Medical

Daily Tip:

Texas Dual-Eligible DME Coinsurance Rules (Cheat Sheet)

🟩 When Texas Medicaid Will Pay Coinsurance

Best-case payer combo:

  • Traditional Medicare (FFS) primary
  • Traditional Medicaid (TMHP FFS) secondary

Requirements:

  • The HCPCS code is a Medicaid-covered benefit
  • TX Medicaid covers the repair/item, regardless of who paid for the chair
    (TMHP FFS is far more generous than MCOs)

Commonly paid (FFS→FFS):

  • Batteries
  • Chargers
  • Motors
  • Joysticks (E2310/E2311)
  • Controllers (E2376)
  • Wiring harnesses
  • Seating repairs
  • Repair labor (K0739)

Summary:
TMHP FFS often pays coinsurance even if the chair was not Medicaid-owned.

🟥 When Texas Medicaid Will NOT Pay Coinsurance

High-denial payer combo:

  • Medicare Advantage (MA) plan primary
  • Medicaid Managed Care (MCO) secondary

Why:

  • Medicaid MCOs must follow Texas Medicaid DME benefit rules
  • Repairs are covered only on equipment that is a Texas Medicaid benefit
  • A chair paid for by Medicare Advantage is not Medicaid-owned
  • Therefore the repair is not a Medicaid-covered service

Result:
If Medicaid wouldn’t cover the repair as primary →
Medicaid MCO cannot legally pay the coinsurance.

⭐ The Golden Rule

If Medicaid wouldn’t cover it as the primary payer, Medicaid will not pay coinsurance as secondary — even for QMB/MQMB clients.

QMB protects the patient, not the provider’s reimbursement.

🟧 Why This Feels Inconsistent

You have seen coinsurance paid before — because those were:

  • Traditional Medicare FFS
  • Traditional Medicaid FFS
  • And the repair code was a TX Medicaid benefit

MCOs do not follow the same crossover logic as TMHP FFS.

🟦 Decision Flow (Quick)

  1. Is Medicare FFS?

    • Yes → likely payable
    • No (MA plan) → go to #2

  2. Is the chair Medicaid-owned / Medicaid-approved?

    • Yes → MCO may pay
    • No → denial is correct

  3. Is the HCPCS a TX Medicaid-covered repair?

    • Yes → payable if #1–2 align
    • No → deny

📌 Key Manual Concepts (TX Medicaid)

  • Repairs are payable only on:
    “client-owned equipment that is considered a benefit of Texas Medicaid.”
  • Medicaid MCOs follow DME benefit policy strictly.
  • TMPPM reimbursement rule:
    Medicaid pays coinsurance only for services that would be covered by Medicaid if Medicare did not exist.

📝 TL;DR

  • Medicare FFS + Medicaid FFS = coinsurance usually paid
  • Medicare Advantage + Medicaid MCO = strict policy → many denials
  • Patient is protected (QMB)
  • Provider payment depends on TX Medicaid’s DME benefit rules, not Medicare’s.