A durable medical equipment (DME) supplier delivering insulin pumps and related supplies sought crossover claim reimbursement for Qualified Medicare Beneficiaries (QMBs) in a Northeastern state. Although the supplier served Medicare beneficiaries residing in the state, Medicaid initially denied the cost-sharing portion of claims because the company did not maintain a physical presence within state borders. While states may impose such requirements for Medicaid-only claims, federal Medicare rules stipulate that all state Medicaid programs must reimburse valid claims for dual-eligible beneficiaries, regardless of a supplier’s physical location.
Applied Policy collaborated with the client to clarify the distinction between Medicaid primary claims and Medicare cost-sharing for QMBs when Medicaid serves as the secondary payer. Drawing on knowledge of Medicare and Medicaid regulations, Applied Policy engaged with CMS personnel in both Baltimore and the regional office, while also guiding the company through the state’s Medicaid enrollment process. Applied Policy provided supporting regulatory citations and documentation to the state’s Medicaid contractor, ensuring the supplier’s eligibility to bill for QMB claims.
As a result, the supplier was successfully enrolled for QMB-only claims and began receiving reimbursement for diabetes equipment and supplies shipped into the state. This resolution allowed the company to continue serving dual-eligible beneficiaries while maintaining compliance with federal requirements and supporting patient access to critical diabetes care.
