B
Definition
The individual who is eligible to receive Medicaid or Medicare benefits, including NEMT. This is the legal term for the "passenger" or "patient" within the context of government insurance.
Overview
Why it Matters
Not all passengers are beneficiaries (e.g., an attendant). Only the Beneficiary generates revenue.
How it Works
The Broker/Provider checks the State's Eligibility File (270/271 EDI transaction) to confirm the person is an active Beneficiary before transport.
Code Comparison
Comparison: Beneficiary vs. Subscriber
Subscriber is typically the primary policyholder (often used in commercial insurance). Beneficiary is the person receiving the government benefit. In Medicaid NEMT, they are effectively the same.
Common Questions
- Lapsed Eligibility: A Beneficiary is eligible on the 1st of the month when booked, but loses eligibility on the 15th (date of service), resulting in a denied claim.
- Dual Eligible: Confusion over whether Medicare or Medicaid is the primary payer for the transport (Medicare usually does not cover routine NEMT; Medicaid does).
- Run eligibility checks on the Date of Service, not just the Date of Booking.
- Verify photo ID at pickup to ensure the person in the car matches the Beneficiary on the manifest.
Sources
CMS.gov - Beneficiary Definition