Crediting Deductible for Non-Inpatient Psychiatric Services

10.7.1 - Crediting Deductible for Non-Inpatient Psychiatric Services (Rev. 11755, Issued:12-21-2022, Effective: 01-23-2023, Implementation: 01-23-23) The Part B deductible for non-inpatient psychiatric services is credited on the basis of the Medicare fee schedule amount. There is no annual limit on incurred expenses for non-inpatient psychiatric services. EXAMPLE 1: An individual received non-inpatient psychiatric services for which a physician charged $250. The $233 Part B deductible had not been met. The GHP allowed $100 and paid $100. The Medicare fee schedule amount is $210. A. Actual charge by the physician minus the third-party payment: $250 - $100 = $150. B. The Medicare payment is determined in the usual manner: $210 - $233 = 0 x .80 = $0. C. Medicare's allowable charge of $210 (which is higher than GHP’s allowed amount of $200) minus GHPs payment of $100 equals $110. Medicare pays $0 (lowest of amounts in steps A, B, or C). The beneficiary can be charged $110 (the $210 fee schedule amount minus the sum of the $100 primary payment plus the $0 Medicare payment). The unmet Part B deductible is credited with $210. The beneficiary still must meet $13 of the annual Part B deductible before Medicare benefits become payable. EXAMPLE 2: An individual received non-inpatient psychiatric services for which the physician charged $250. None of the individual's Part B deductible had been met. The GHP allowed charges in full and paid $250. The Medicare fee schedule amount for the services was $200. No Medicare secondary benefit is payable since the GHP paid charges in full. The $233 Part B deductible is credited by the first $200 of the fee schedule amount. The beneficiary cannot be billed by the physician because the sum total of the primary payment ($250) and the Medicare payment ($0) exceeds the fee schedule amount ($200). EXAMPLE 3: An individual received non-inpatient psychiatric services from a physician for which the physician charged $500. None of the individual's $233 Part B deductible had been met. A GHP allowed charges in full and paid $400 (80 percent of the $500). The Medicare fee schedule amount for the services was also $500. The $233 Part B deductible is credited in full. The Medicare secondary benefit calculated is $100. The physician cannot bill the beneficiary because the sum total of the primary payment ($400) and the Medicare secondary payment ($100) equals the Medicare fee schedule amount.