14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.21 Loss of Medicaid Coverage for Special Needs Plan Members
Amerigroup/Amerivantage
Amerivantage Dual Coordination (HMO SNP) members are either full dual-eligible beneficiaries (FBDE) with
both Medicare and full Medicaid benefits, or they have Medicare and are considered Qualified Medicare
Beneficiaries (QMB or QMB Plus).
In New Jersey, New Mexico and Texas, individuals considered Specified Low-Income Medicare Beneficiaries (SLMB Plus) can also enroll in the Amerivantage Dual Coordination (HMO SNP). Medicare members who temporarily lose their Medicaid coverage may be required to pay cost sharing and copays for services until their Medicaid coverage is re-established. Members are encouraged to be cognizant of their eligibility to ensure there is no loss or gap in coverage that would result in liability of cost share.
If the Part A deductible and Part B deductible are not already met at the time of the beneficiary’s loss of coverage, the member will be responsible for the extended Length of Services (LOS) per diem cost share for inpatient facilities and/or any coinsurance on professional and outpatient services.