Coinsurance Election

30.1 - Coinsurance Election (Rev. 12423; Issued: 12-20-23; Effective: 01-01-24; Implementation: 01-02-24) The transition to the standard Medicare coinsurance rate (20 percent of the APC payment rate) will be gradual. For those APC groups for which coinsurance is currently a relatively high proportion of the total payment, the process will be correspondingly lengthy. The law offers hospitals the option of electing to reduce coinsurance amounts and advertise their reduced rates for all OPPS services. They may elect to receive a coinsurance payment from Medicare beneficiaries that is less than the wage adjusted coinsurance amount per APC. That amount will apply to all services within that APC. This coinsurance reduction must be offered to all Medicare beneficiaries. Hospitals should review the list of APCs and their respective coinsurance amounts that is published in the Federal Register for the applicable year as a final rule. After adjusting those coinsurance amounts for the wage index applicable to their MSA, hospitals must notify their A/B MACs (A) if they wish to charge their Medicare beneficiaries a lesser amount. The election remains in effect until the following calendar year. The first election must be filed by July 1, 2000, for the period August 1, 2000, through December 31, 2000. Future calendar year elections must be made by December 1st of the year preceding the calendar year for which the election is being made. Because the final rule on OPPS payment rates for 2002 was not published until March 1, 2002, providers were unable to make election decisions for 2002 by December 1 preceding the year the payment rates became effective, the typical deadline for making such elections. The deadline for providers to make elections to reduce beneficiary copayments for 2002 was extended until April 1, 2002. The elections are effective for services furnished on or after April 1, 2002. The lesser amount elected: • May not be less than 20 percent of the wage adjusted APC payment amount; • May not be greater than the inpatient hospital deductible for that calendar year ($812 for 2002); and • Will not be wage adjusted by the A/B MAC (A) or CMS. Once an election to reduce coinsurance is made, it cannot be rescinded or changed until the next calendar year. National unadjusted and minimum unadjusted coinsurance amounts will be posted each year in the addenda of the OPPS final rule (enter CMS1005FC) on CMS’ Web site (http://cms.hhs.gov/). This coinsurance election does not apply to partial hospitalization or intensive outpatient services furnished by CMHCs, vaccines provided by a CORF, vaccines, splints, casts, and antigens provided by HHAs, or splints, casts, and antigens provided to a hospice patient for the treatment of a non-terminal illness. It also does not apply to screening colonoscopies, screening sigmoidoscopies, or screening barium enemas, or to services not paid under OPPS. Hospitals must utilize the following format for notification to the A/B MAC (A): Provider number 1122334455 Provider name XYZ Hospital Effective from 8/1/2000 - 12/31/2000 Provider contact Joe Smith Phone # 123-456-7890 Contact e-mail Jsmith@XYZ.ORG Fax # 123-456-7891 XYZ Hospital elects to reduce coinsurance to the amount shown for the following APCs: APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ Return to: Provider Audit & Reimbursement Dept. Attn: John Doe A/B MAC (A) Address The A/B MAC (A) must validate that the reduced coinsurance amount elected by the hospital is not less than 20 percent of the wage adjusted APC amount nor more than the inpatient deductible for the year of the election, and must send an acknowledgment to the hospital that the election has been received, within 15 calendar days of receipt.