Deductible and/or Coinsurance Rates Spanning Two Calendar

40.8.10 - Deductible and/or Coinsurance Rates Spanning Two Calendar Years (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Where Medicare is secondarily liable because another payer primary to Medicare has made payment on an inpatient claim and the stay spans two calendar years, the provider bills the deductible and/or coinsurance rate applicable to the year in which Medicare utilization is charged. Medicare utilization (calculated in accordance with the above instruction) is charged beginning with the first day of the stay. This rule applies even though the primary payer paid for only a specified number of days of a stay, e.g., the primary payer's plan covers the first 20 days of a 30-day stay. Where Medicare utilization involves coinsurance days spanning two calendar years, the provider bills coinsurance for each coinsurance day in accordance with the applicable coinsurance rate for the year in which the day was used. The provider uses value codes 09 and 11, form locators 39 through 41, to show specific coinsurance amounts. See CWF documentation for reporting coinsurance days on the CWF record. EXAMPLE l: A beneficiary is in a new benefit period and was admitted to the hospital on December 15, 2021, and discharged on January 14, 2022. An insurer primary to Medicare paid the first 20 days of the stay. The provider bills the $1,484.00 deductible (the applicable deductible for the first year in which Medicare utilization is charged). EXAMPLE 2: A beneficiary was admitted to the hospital on December 15, 2021, and discharged on January 14, 2022. Only coinsurance days were available. An insurer primary to Medicare paid the first 20 days of the stay. After performing the utilization calculation, the provider determined the beneficiary can be charged with 10 days utilization (December 15 thru December 24). The provider bills 10 days coinsurance at the 2021 rate ($371 x 10 = $3,710). The coinsurance amount is based upon the inpatient hospital deductible for the year in which days are used. EXAMPLE 3: A beneficiary was admitted to the hospital on December 25, 2021, and discharged on January 24, 2021. Only coinsurance days were available. An insurer primary to Medicare paid the first 20 days of the stay. After performing the utilization calculation, the provider determined the beneficiary can be charged with 10 days utilization (December 25, 2021 thru January 3, 2022). The provider bills 7 days coinsurance at the 2021 rate ($371 x 7 = $2,597) and 3 days coinsurance at the 2022, rate ($389 x 3 = $1,167). The coinsurance amount is based upon the inpatient hospital deductible for the year in which days are used. The data is reported on the Form CMS-1450 as follows: • Value Code 09, Medicare Coinsurance Amount in First Calendar Year = $2,597; • Value Code 11, Medicare Coinsurance Amount in Second Calendar Year = $1,167; • Form Locator 9, Coinsurance Days =10