SECTION 354.1041. Benefits for Medicare/Medicaid Recipients

For recipients who are eligible for both Medicare and Medicaid (dual eligible), Medicare is the primary payor.

(1) Medicaid will pay the Medicare deductible and coinsurance subject to the limitations described in §354.1143 of this subchapter (relating to Coordination of Medicaid with Medicare Parts A, B, and C) for qualified recipients of home health services.

(2) Eligible recipients who have exhausted their home health benefits under Medicare are not entitled to receive all home health services under the Medicaid program. Home health aide services, DME, supplies, or appliances may be a covered service if:

(A) an eligible Medicaid recipient enrolled in Medicare does not qualify for home health services under Medicare because skilled nursing care, physical therapy, speech therapy or occupational therapy is not an essential element of the recipient's treatment plan; and/or

(B) the medical supplies, equipment, or appliances for use in the eligible recipient's place of residence are not otherwise available as a Medicare Part B benefit.

Source Note: The provisions of this §354.1041 adopted to be effective June 26, 1997, 22 TexReg 5826; 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