Coordination of Benefits Question (U65 on Medicare)

[TN_agent]

Somarco, I did read what you provided. I was still unclear on patient responsibility.

I think LD found the answer I was looking for.

I didn't have time to read the whole document LD linked to, but it seems like she could only be personally billed by a provider for a maximum of her portion of Medicare charges as if she only had original Medicare, UP TO assignment (whatever her portion is based on GHP paying what they are obligated to pay, then Medicare paying, which may be little or nothing). In many cases, it seems like she won't be billed for anything if what GHP has paid is more than Medicare assignment.

LD, I did the math in my head, just rounding error on my part, but the assignment is more than $1200 so there would be a balance due from someone, just not Medicare.

 

[goillini52]

It looks like
10.1.2 of this:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf

Addresses your question. I don't have the time right now to paper,pencil and calculator convert the manual example to your example, but it kinda seems like the situations match.

(And I deleted my previous post because it is totally stupid in relation to this situation.)

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Edit-to Somarco
I'm sorry, deleting my post messed up your ref to post 8, it's now post 7.
The stuff i said was so inappropriate to the thread that it was not good to leave it.
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I get the provider being able to bill an additional $28.40.

GHP paid $1200.
Medicare allows $1500.
$1500-$182=$1308 x .8 = $1046.40 Medicare payment if Medicare primary.

Medicare primary pmt $1046.40 + medicare ded $182 = $1228.40
(Medicare Ded + Medicare coinsurance)

GHP pmt $1200 - Medicare amt $1228.40 = - 28.40 (the amount which the provider could recover from the patient.)

LD, get that pecil back out. The Part B deductable is $183...not $182.

 

[LostDollar]

I made a mistake in my math (with a calculator)!
Also think I did the approach wrong.

It keeps seeming like there would be no additional charge to the beneficiary.

In your example the primary plan determines a payment of $1200.
Medicare says their payable as primary amount without regard to deductible or coinsurance is $1500.

Medicare deductible = $183.
Medicare coins amt (1500-183)*.8 = $1054.
ApplicableMedicare deductible + coins = $1237.

GHP pmt $1200 < $1237 above.

This activates 2nd choice under 10.1.2

(there appear to be technicalities relating to precise definitions of provider, physician, other suppliers in the Medicare lexicon.)

Primary plan pmt $1200 + Medicare (presumed) secondary pmt (a) $1054 = $2254
The Medicare fee schedule amount is only $1500.
so the physician/supplier is unable to bill any additional amount to the beneficiary (under 10.1.2).

(a) I have attempted to follow the mechanics of the example in the CMS manual in putting this number here.

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Terms:
Including provider and supplier

https://www.cms.gov/Medicare/Provid...MedicareProviderSupEnroll/downloads/Terms.PDF

 

[somarco]

FWIW, I have never seen a claim where Medicare paid anything when they were secondary to group health insurance.

The Medicare B premium for 2017 is $134/mo for those not impacted by IRMAA.

If your client expects Medicare (as a secondary payer) to pay more than $1608 in claims for the year, then they should buy in. Otherwise it is like almost every other situation where "dual coverage" exists.

It is a waste of money.

 

[LostDollar]

This is all very confusing to me.

I am unable to get to the viewpoint of seeing that Medicare does not pay anything which is stated several times in the thread.

There is a section in the CMS MSP manual that talks about when physicians and other suppliers may bill the Medicare beneficiary in a coordinated payment situation.

There is a Federal Code section that prescribes a 3 step computation to determine what Medicare will pay on a specific claim as a secondary payer.

There is a manual section by Medicare Contractor CGS which seems to change the code instructions to two computations.

However, all of the examples in those references show Medicare making claim payments.

The best sense I can make out of all that at this time, for the situation OP presented in post one is that the lady would have no liability and Medicare would pay $300 as secondary payer.


CMS MSP Manual:
https://www.cms.gov/Regulations-and...ternet-Only-Manuals-IOMs-Items/CMS019017.html

Limitations on right to charge beneficiary (CH3 msp manual):
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf

42 CFR 411.33 - Amount of Medicare secondary payment:
https://www.law.cornell.edu/cfr/text/42/411.33

Medicare Administrative Contractors (MACs):
https://www.cms.gov/Medicare/Medica...ractors/Downloads/MACs-by-State-July-2016.pdf

Contractor CGS manual, chapter 11:
https://www.cgsmedicare.com/jc/pubs/pdf/chpt11.pdf
(This appears to leave out one of the 3 computations in the code of federal regulations.)

 

[VolAgent]

LD, something to keep in mind. Just because something can happen, doesn't mean it actually will. It appears most group plans have steep enough discounting and rich enough plan design that there is nothing left that Medicare will pay.

 

[TN_agent]

LD, look at the example in section 10.1.1 of the original document you cited (text below)

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 nonpayment bill reflecting the applicable deductible for purposes of crediting the deductible.

 

[OHenry]

Thank you all for the great detailed discussion. Learned exactly what I needed to know and have been looking for the past several days!

 

[somarco]

Three year old thread. Lot's of "what if's" posted by some of the participants.

FWIW, since this thread appeared almost 3 years ago I have been personally involved in an MSP claim.

My wife is 65+, actively employed, covered by EGH (primary) and Medicare Part A only but not B. Last year she fell and broke her hip. Five days inpatient for surgery (screws to stabilize the head of the femur) followed by 5 months of outpatient care, mostly PT.

Her plan has a $3500 deductible then coinsurance to a max $6k OOP.

The surgeon submitted his bill to the carrier before the hospital, so we took the deductible hit on outpatient charges, not the hospital.

Hospital inpatient gross bill was $51k, repriced by the carrier to $22k. Carrier paid the lions share of the bill leaving almost $2900 due.

Medicare paid $2200 leaving us to pay the remaining $700.

That's a nice return on "free" Medicare insurance.

 

[OHenry]

Very sorry this had to happen to your wife. Hopefully her recovery was good. Your "real life" example is easy to understand and reassuring that it does not always have to be a nightmare to figure out.... or to have to pay!

May I ask if you had ever considered cancelling the EGH policy and use those saved premiums to pay for most of the premiums associated with buying Part B medicare, a Supplemental medigap plan, (and the cheap Part D presc plan) If you only had Medicare A, B, and the Supplemental Plan, would not that have saved you from having to pay the $3500 deductible and the $6000 OOP in your wife's case?

I only ask because I am trying to help my sister, who has stage 4 cancer, make that same decision within the next couple of days!

Her case is somewhat unusual because of 2 things. I had posted a thread yesterday about this. If you have a chance it would be great if you could take a look and maybe post any comments you might have.

P.S. I am not an agent but have a basic understanding from reading things on the subject over the past couple of months. This stuff is 10 times more complex than causality ins which I experienced in a previous lifetime as an adjuster. So if you are able to shed any light on my decision about keeping or dropping the Group plan, hopefully I can keep up with understanding what is turning out to be a very complex subject for me.

HERE IS THE LINK OF MY POST
https://insurance-forums.com/commun...ork-primary-vs-secondary.100945/#post-1336969