Right of Providers to Charge Beneficiary Who Has Received

10.1.1 - Right of Providers to Charge Beneficiary Who Has Received Primary Payment from a GHP (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) When a primary plan has paid a beneficiary, the amounts the provider (including renal dialysis facilities or facilities that receive direct payment from the Medicare program) may collect for Medicare covered services from the beneficiary are limited to the following: • The amount paid or payable by the primary plan to the beneficiary. If this amount exceeds the amount which would have been payable by Medicare as primary payer (without regard to deductible or coinsurance), the provider may retain the primary payment in full without violating the terms of the provider agreement; • The amount, if any, by which the applicable Medicare deductible and coinsurance amounts exceed any primary payment made or due the beneficiary or due the provider for medical services; and • The amount of any charges made to the beneficiary for the noncovered component of a partially covered service, e.g., the charge differential for a private room that is not medically necessary but that is requested by the beneficiary. However, such a charge may not be collected from the beneficiary to the extent that the primary plan pays it directly to the provider. EXAMPLE A Medicare beneficiary with GHP coverage was a hospital inpatient for 20 days. The hospital's charges for Medicare covered services were $16,000. The inpatient deductible had not been met. The gross amount payable by Medicare for the stay in the absence of GHP coverage is $11,500. The GHP paid $14,000, a portion of which was credited to the entire inpatient deductible. Medicare makes no secondary payment, since the GHP’s payment was greater than the gross amount payable by Medicare of $11,500. No part of the $2,000 difference between the hospital's charges and the GHP’s payment can be billed to the beneficiary, since the beneficiary's obligation, the deductible, was met by the GHP’s payment. The provider files a non-payment bill reflecting the applicable deductible for purposes of crediting the deductible.