GHP Does Not Pay Because of Deductible or Coinsurance Provision

40.3.2 - GHP Does Not Pay Because of Deductible or Coinsurance Provision (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) A GHP may reduce benefits by deductible and coinsurance amounts. If such provisions apply to all policyholders, Medicare pays secondary benefits with respect to Medicare covered expenses that are not reimbursable under the GHP contract. Therefore, if a GHP has been billed and has made no payment or only partial payment because of a deductible or coinsurance, Medicare may pay. Before paying such a claim, the A/B MAC and the DME MAC requires an explanation of benefits or payment, or adjustment information found on the 837 claim from the GHP showing the status of the deductible after taking into account the expenses for which Medicare is being billed.