Effect of GHPs Payments on Deductible, Coinsurance,

10.7 - Effect of GHPs Payments on Deductible, Coinsurance, and Utilization (Rev. 11755, Issued:12-21-2022, Effective: 01-23-2023, Implementation: 01-23-23) Expenses that serve to meet the beneficiary's Part A or Part B cash and blood deductibles, if Medicare were primary payer, are credited to those deductibles even if the expenses are reimbursed by a GHP. This is true even if the GHP paid the entire bill and there is no secondary Medicare benefit payable. If a GHP paid for Medicare covered expenses in whole or in part, the Part B deductible is credited on the basis of the Medicare fee schedule amount rather than the amount paid by the GHP. Also, GHP payments to a provider are applied to satisfy a beneficiary's obligation to pay a Part A or Part B coinsurance amount. However, GHP payments are credited to deductibles before being used to satisfy the coinsurance. Where no Medicare secondary benefit is payable, no utilization is charged the beneficiary. Where a Medicare secondary payment is made, the A/B MAC charges the beneficiary with utilization. These procedures are applicable for calculating utilization for stays for which Medicare is secondary only for a portion of the stay. Expenses for which payments are made and Medicare conditional payments are recovered from no-fault or liability insurance are credited toward the deductible amounts for both Parts A and B. Also, no-fault and liability payments are applied to satisfy a beneficiary's obligation to pay Part A or Part B coinsurance amounts. No-fault and liability payments are credited to deductibles before being used to satisfy the coinsurance. For services provided prior to November 13, 1989, payments by the primary payer are not counted toward the Medicare deductible. The discharge date is used for determining when a provider furnished the services. Services for which Medicare conditional payments are recovered from liability or no- fault insurance are not counted against the number of inpatient care days available to the beneficiary. If an individual is hospitalized twice in the same benefit period and Medicare recovers its payment from a no-fault or liability insurance for the first hospitalization, the first hospitalization would not be charged to the beneficiary. See CFR 42 § 411.30 and 411.33 EXAMPLE 1: An individual who previously had not met any of the $233 Part B deductible incurred $233 in charges for which the GHP paid $200. The Medicare fee schedule amount was $233. No Medicare benefits are payable. The individual is credited with $233 toward the Part B cash deductible. The beneficiary can be charged $33. (The $233 fee schedule amount minus the sum of the $200 primary payment plus the $0 Medicare payment). EXAMPLE 2: An individual who previously had met $100 of the $233 Part B deductible incurred $150 in charges that were paid in full by the GHP. The Medicare fee schedule amount was $150. No Medicare benefits are payable. The individual is credited with an additional $150 toward the Part B cash deductible and now has satisfied the Medicare deductible. The physician cannot bill the beneficiary because the sum total of the primary payment ($150) and the Medicare payment ($0) meets the fee schedule amount of ($150).