Medicare deductible, coins - can we collect from patient when patient have secondary insurance

The Medicare Program

The Original Medicare Program, also known as Fee-For-Service (FFS) Medicare, consists of:

• Part A, hospital insurance; and

• Part B, medical insurance.

Under FFS Medicare, eligible individuals may enroll in Part A, Part B, or both Part A and Part B. Most individuals choose to enroll in both Part A and Part B.

FFS Medicare was expanded in 1973 to include:

• Individuals who are under age 65 with certain disabilities; and

• Individuals with End-Stage Renal Disease.

Two parts were added to the Medicare Program in 1997 and 2006, respectively:

• Part C, Medicare Advantage (MA) (first known as Medicare+Choice); and

• Part D, the Prescription Drug Benefit.

MA is another health plan choice available to beneficiaries. It is a program run by Medicare-approved private insurance companies. Most MA organizations arrange for or directly provide health care items or services to the beneficiary who:

• Is entitled to Part A and enrolled in Part B;

• Permanently resides in the service area of the MA Plan; and

• Elects to enroll in a MA Plan.

The Prescription Drug Benefit provides prescription drug coverage to all beneficiaries enrolled in Part A and/or Part B who elect to enroll in a Medicare Prescription Drug Plan (PDP) or a MA Prescription Drug Plan. Insurance companies or other companies approved by Medicare provide prescription drug coverage to such individuals who live in the Plan’s service area. Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for PDP costs.

The Medicaid Program

The Medicaid Program is a cooperative venture funded by Federal and State governments that pays for medical assistance for certain individuals and families with low incomes and limited resources. Within broad national guidelines established by Federal statutes, regulations, and policies, each State:

Patient's rights and responsibilities at provider office

Member’s Rights & Responsibilities

SHP Members have the right to:

*  be treated with courtesy and respect, and with due consideration of his/her dignity and privacy.

*  receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand.

*  participate in decisions regarding his or her health care, including the right to refuse treatment.

*  be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

*  request and receive a copy of his or her medical records, and request that they be amended or corrected.

*  be furnished health care services in accordance with federal and state regulations.

The State must ensure that each enrollee is free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way the health plan and its providers or the State agency treat the enrollee.

They also have the right to

*  Receive a prompt and reasonable response to questions and requests

* Know who is providing medical services and who is responsible for his/her care

* Know what member support services are available, including whether an interpreter is available if he/she does not speak English

*  Know what rules and regulations apply to his/her conduct

*  Be given, upon request, full information and necessary counseling on the availability of known financial resources for his/her care

*  Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care and receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained for services not covered by SHP

* Impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment

* Treatment for any emergency medical condition that will deteriorate from failure to provide

treatment

* Be advised if medical treatment is for purposes of experimental research and be able to give his/her consent or refusal to participate in such experimental research

* Express grievances regarding any violation of his/her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him/her and to the appropriate state licensing agency 

Can we billed Medicaid patient for Medicare coins ?

Can you clarify if Medicaid only covers Medicare part B premium? Is the patient responsible for the 20% coinsurance?

If you are referring to persons who only have coverage as Special Low Income Medicare Beneficiaries (SLMB) or as Qualifying Individuals I (QI1), this would be correct, but note that it is possible for a person to be eligible for both SLMB and a full Medicaid coverage program at the same time. Crossover claims policy would apply for those persons. More information can be found in the Florida Medicaid Provider General Handbook

Patients that are enrolled in a Medicare Advantage Plan still think that they have Medicaid second. What can we do to help us and them?

Florida Medicaid covers the Medicare Part C deductible and coinsurance up to the Medicaid fee, less any amounts paid by Medicare. If this amount is negative, no Medicaid payment is made. If this amount is positive, Medicaid pays the coinsurance and deductible up to the billed or allowed amount, whichever is less. The Florida Medicaid system is in the process of being programmed to comply with the state’s policy governing Medicare Advantage plan copayments. The system changes will be retroactive to January 1, 2010

Slide 38 of the presentation states that full Medicaid over-rules lower programs. Then, on slide 61 it states that as the recipient is QMB along with full Medicaid, the provider can bill for level of care (Medicare coinsurance). Could you please clarify this issue?

The QMB coverage means that the person has Medicare (another payer) in addition to the Medicaid coverage. The “level of care” refers to Nursing Facilities. Even though this person does not have the Long Term Care Medicaid, they have Medicare that could pay for Nursing Facility days (up to a limit). In this case the facility can bill Medicaid for part A coinsurance only – level of care =X. Of course, during the process of verifying eligibility, you would have already seen the Medicare coverage information.

SLMB: What is the definition of a Medicare Premium?

The Medicare premium is the amount that a person with Medicare Part A and/or Medicare Part B pays to Medicare to receive coverage.

Billing patient for non - covered service - consent form

Charging members for non-covered services

For Commercial members, you may seek and collect payment from our member for services not covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. In those instances in which you know or have reason to know that the service may not be covered (as described below), the written consent also must: (a) include an estimate of the charges for that service; (b) include a statement of reason for your belief that the service may not be covered; and (c) in the case of a determination by us that planned services are not covered services, include a statement that UnitedHealthcare has determined that the service is not covered and that the member, with knowledge of UnitedHealthcare’s determination, agrees to be responsible for those charges.

For Medicare Advantage members, a Notice of Denial of Medical Coverage must be provided to the member advising them when a service is not covered.

IMPROVING SELF-PAY PATIENTS PAYMENT COLLECTION

DESCRIPTION OF THE ISSUE

Self-pay uncollected balances were not directly moved towards Collection Agency.  We made an analysis from our end to find reason for unpaid balances and came with appropriate solutions to gain payments to the provider.

CONCEPT

Unpaid Patient balances not to be moved directly towards Collection Agency.  Even we could make a research on the reason for its non-payment from our end.

SOLUTION

We started verifying patients’ addresses from Hospital’s website and updated new addresses for the patients and forwarded statements.  Also verified whether those patients had any coverage information, if so, we started filing those claims to the carriers for reimbursement.

Can we bill patient for not updating COB

Coordination of Benefits

Coordination of benefits (COB) refers to two or more insurance plans covering one individual, coordinating their respective benefits to share the cost of health care. COB rules identify one plan as the primary payer (this plan pays regular contract benefits first) and the other plan as secondary (this plan pays the balance of charges up to the limits of its contract, but never more than what it would have paid if primary).

It is the member’s responsibility to provide other insurance information to BCBSF annually. A form is mailed to the member to complete and return. Many of our members may also update their other insurance information directly online. Providers can access the BCBSA COB Questionnaire on our website, www.bcbsfl.com and also request copies of our COB brochure. 

Members who do not update other insurance information may have their claims denied and will be responsible for the charges. Providers may bill the member for services that were denied for lack of other

insurance information.