14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.18 Cost-Sharing Responsibility for Special Needs Plan Members
| Amerivantage SNP + Rx Member | Amerivantage Classic + Rx Member | Amerivantage Balance + Rx Member | Rationale |
| Claim is process at 100 percent of the provider's contract rate. | Claim is process according to your contracted rate munus any applicable cost sharing as filed in the member's benefit package. | N/A | Health plan pays cost sharing as field in their Medicare bids. The provider does not bill the state. |
Members that are dually eligible, either as full benefit dual eligible or as part of a Medicare Savings Program, are protected from liability of Medicare premiums, deductible, coinsurance and copayment amounts. This includes cost share being applied to this/these claims. Providers may not bill a dual eligible that has this coverage for any balance left unpaid (after submission to Medicare, a Medicare carrier and subsequently Medicaid) as specified in the Balanced Budget Act of 1997. Providers that service dual eligible beneficiaries must accept as payment in full the amounts paid by Medicare as well as any payment under the state Medicaid processing guidelines. Providers who balance bill the dual eligible beneficiary are in violation of these regulations and are subject to sanctions. Providers also may not accept dual eligible beneficiaries as ‘private pay’ in order to bill the patient directly and providers identified as continuing to bill dual eligible beneficiaries inappropriately will be reported to CMS for further action/investigation.
The rules governing balance billing as well as the rules governing the MA payment of MA-plan, noncontracting and Original-Medicare, nonparticipating providers are listed below by type of provider.
Contracted provider
There is no balance billing paid by either the plan or the enrollee.
Noncontracting, Original Medicare, participating provider
There is no balance billing paid by either the plan or the enrollee.
Noncontracting, non-(Medicare) participating provider
The MAO owes the noncontracting, nonparticipating (non-par) provider the difference between the member’s cost-sharing
and the Original Medicare limiting charge, which is the maximum amount that Original Medicare requires an MAO to reimburse
a provider. The enrollee only pays plan-allowed cost-sharing, which equals:
- The copay amount, if the MAO uses a copay for its cost-sharing; or
- The coinsurance percentage multiplied by the limiting charge, if the MAO uses a coinsurance method for its cost-sharing. MA-plan, noncontracting, nonparticipating DME supplier.
The MAO owes the noncontracting nonparticipating (non-par) DME supplier the difference between the member’s cost-sharing and the DME supplier’s bill; the enrollee only pays plan-allowed cost-sharing, which equals:
- The copay amount, if the MAO uses a copay for its cost-sharing; or
- The coinsurance percentage multiplied by the total provider bill, if the MAO uses a coinsurance method for its cost-sharing. Note that the total provider bill may include permitted balance billing.
Additional useful information on payment requirements by MAOs to non-network providers may be found in MA Payment Guide for Out-of-network Payments.
MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits their cost-sharing obligations as well as their lack of obligation to pay more than the allowed plan cost-sharing as described above.
If you are a non-contracting non-participating Medicare provider, who does not accept Medicare assignment, please contact us if there are any questions regarding your claim(s) payments.