No-Fault Insurance Does Not Pay All Charges Because of Deductible or

40.7 – No-Fault Insurance Does Not Pay All Charges Because of Deductible or Coinsurance Provision in Policy (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) In a number of States, no-fault insurers may reduce no-fault insurance benefits by deductible or coinsurance amounts or may offer the option for such a reduction. If such contract provisions apply to all policyholders, Medicare pays benefits with respect to otherwise Medicare-covered expenses that are not reimbursable under such a no-fault contract. Therefore, if a no-fault insurer has been billed and has made no payment because of a deductible or coinsurance, or only a partial payment (e.g., the insurance deductible has been bridged), the claimant may bill Medicare following the procedures set forth in the Medicare Claims Processing Manual for billing for secondary Medicare benefits. If no payment was made under no-fault, the MSP Contractor applies the usual Medicare deductibles and coinsurance in calculating the Medicare secondary payment. See 42 CFR §§ 411.50-411.53. For example, the beneficiary receives outpatient hospital services covered by no-fault insurance. The total charges are $200. The no-fault insurer is billed for $200, but makes no payment because of a $1000 deductible in policy. The hospital then bills Medicare for $200.