Members are only responsible for applicable copayments, deductibles and coinsurance associated with their benefit plans. You should collect copayments at the time of service; however, to determine the exact member responsibility related to the benefit plan deductibles and coinsurance, if any, we recommend that you submit claims first and refer to the appropriate Explanation of Benefits (EOB) when billing members.
Annual Copayment/Deductible Maximum (Commercial)
Annual out-of-pocket maximum is the combined total of annual deductible (if any) and annual copayment maximum (if any), as shown on the member’s Schedule of Benefits. Cost share is defined as amounts paid by the member such as copayments, coinsurance and deductibles according to their plan benefits. Cost sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Please refer to the member’s Schedule of Benefits to determine applicability to the benefit plan.
When an individual member’s out-of-pocket expenses has reached the Individual out-of-pocket maximum, the member will not have any additional cost shares for those services that apply to the out-of-pocket maximum for that year.
For benefit plans with both Individual and Family maximums, no member of the family will owe further cost share amounts for those services that apply to the out-of-pocket maximum. When a family’s out-of-pocket expenses have reached their family out-of-pocket maximum benefits plans with benefits that do not apply to the out-of-pocket maximum will still require cost sharing for those excluded benefits after the out-of-pocket maximum reached.
Some services may not be covered until the member meets the annual deductible. Only amounts incurred for covered services that are subject to the deductible will count toward the deductible. Benefit plans may have an individual deductible only or both individual and family deductible amounts. No further deductible will be required for the individual member when the individual deductible amount has been satisfied for the year. For plans with both individual and family deductibles, no further deductible will be required for all members of the family unit when members of the family unit satisfy the family deductible for the year.
As specified above, only certain covered services apply to the annual deductible. Other covered services not included in the annual deductible may incur a member cost share considered separate from and not applied to the annual deductible. The annual deductible applies to the annual out-of-pocket maximum. The amounts applied to the annual deductible based upon UnitedHealthcare’s contracted rates, percentage copayments (coinsurance) and contracted rates.
Annual Out-of-Pocket Maximum (Medicare Advantage)
Annual out-of-pocket maximum is the total of the member’s annual copayment maximum (if any), as shown on the member’s Evidence of Coverage.
Cost sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Please refer to the member’s Evidence of Coverage to determine applicability to the benefit plan. When an individual member’s out-of-pocket expenses has reached the Individual annual out-of-pocket maximum, no further cost share amounts will be due by the member for those services that apply to the annual out-of-pocket maximum. Plans with benefits that do not apply to the annual out-of-pocket maximum will still require cost sharing for those excluded benefits after the annual out-of-pocket maximum reached.
Cost share defined as amounts paid by the member such as copayments, coinsurance and deductibles according to their plan benefits.
Additional Fees for Covered Services
Do not charge additional fees for:
- Covered services beyond their copayments, coinsurance, or deductible
- Concierge/boutique practice fees
- Retainers, membership, or administrative fees
- Denied services/claims because you failed to follow our protocols and/or reimbursement policies
You may charge members for:
- Missed appointments
- CMS does not allow you to charge MA members for missed appointments unless the member was aware of that policy
- Completion of certain forms (described in the previous section)
Charging Members for Non-covered Services
You may collect payment from our commercial members for services not covered under their benefit plan, if you first get the member’s written consent. The member must sign and date the consent before the service is done. Keep a copy of this in the member’s medical record. The consent must include:
- An estimate of the charges for that service;
- A statement of reason for your belief the service may not be covered; and
- When we determine the planned services are not covered services, a statement that we have determined the service is not covered and that the member knows our determination, and agrees to be responsible for those charges.
You must follow this process if you know, or have reason to suspect that their benefits may not cover the service.
For MA members, in addition to the member’s written consent, you must do the following:
- If you know or have reason to believe that a service or item you are providing or referring may not be covered, request a pre-service determination from us prior to rendering services.
- If we determine the service or item is not covered, we issue an Integrated Denial Notice (IDN) to the member and you. The IDN gives the member their cost for the non-covered service or item and appeal rights. You must make sure the member has received the IDN prior to rendering or referring for non-covered services or items to collect payment. Per CMS requirements, for you to hold a MA member financially liable for the non-covered service or item, the member must first have an IDN, unless the Evidence of Coverage (EOC), or other related materials, clearly excludes the item or service.
- A pre-service organization determination is not required to collect payment from a MA member where the EOC or other related materials is clear that a service or item is not covered.
When you submit an advance notification request using UHCprovider.com/priorauth, you are requesting a pre- service organization determination. A service or item may not be covered if:
- We have provided notice through an article on UHCprovider.com including clinical protocols, medical and drug policies, and/or coverage determination guidelines; or
- We have made a determination that the planned service or item is not covered and have communicated that determination.
- For MA benefit plans, CMS has published information to help you determine if the service or the item is covered. You are required to review the Medicare Coverage Center. If you do not follow this protocol, you cannot bill our member.
If you followed this protocol and requested a pre-service organization determination and an IDN was issued before the non-covered service was rendered, you must include the –GA modifier on your claim for the non-covered service. Including the –GA modifier on your claim helps ensure your claim for the non-covered service is appropriately adjudicated as member liability.
Do not bill the member for non-covered services in cases where you do not follow this protocol. If you don’t follow the terms of this protocol (such as requesting a pre-service organization determination for a MA member or rendering the service to a MA member before we issue the pre- service organization determination), you may receive an administrative claim denial. You cannot bill the member for administratively denied claims.
You cannot bill the the member for covered services beyond their normal cost sharing amounts (copayment, deductible, or coinsurance).
For MA members eligible for Medicaid, you cannot:
- Collect a deposit,
- Seek compensation,
- Seek remuneration,
- Seek reimbursement, or
- Have recourse against the member or their representative, or the MA organization.
You must either:
- Accept payment made by or on behalf of the MA organization as payment in full; or
- Bill the appropriate state source for such cost-sharing amount.
Qualified Medicare Beneficiaries (QMB) are not responsible for Medicare cost sharing under CMS regulations. Medicare cost sharing includes the deductibles, coinsurance and copays included under MA Plans. You cannot bill, charge, collect a deposit from, seek compensation from any MA member who is eligible for both Medicare and Medicaid. You can accept payment from us as payment in full or bill Medicaid for the remaining amount.