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Charging Members - Chapter 10, 2019 UnitedHealthcare Administrative Guide

Members are only responsible for copayments, deductibles and coinsurance. You should collect copayments at the time of service. For the exact amount of member responsibility, submit the claims first and refer to the Explanation of Benefits (EOB).

Annual Copayment/Deductible Maximum (Commercial)

Annual out-of-pocket maximum is the combined total of annual deductible and annual copayment maximum, as shown on the member’s Schedule of Benefits. Cost share is the amount the member is financially responsible for, 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 after the family has met the out-of-pocket maximum. When a family’s out-ofpocket 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 previously indicated, 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 are based upon UnitedHealthcare’s contracted rates, and percentage copayments (coinsurance). 

Annual Out-of-Pocket Maximum (Medicare Advantage)

Annual out-of-pocket maximum is equal to 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-ofpocket maximum will still require cost sharing for those excluded benefits after the annual out-of-pocket maximum reached.

Coinsurance Calculation

For all MA products, coinsurance is calculated as follows:

  1. For services reimbursed on a service-specific contracted rate, or on a fee-for-service basis, the coinsurance is based on the contracted rate or billed amount, whichever is less or as agreed upon in your Agreement with us.
  2. For services reimbursed under a downstream capitation Agreement between your organization and a care provider of the service, and where payment is not issued for each specific service rendered, coinsurance is based on Medicare’s allowance for the location at which the service is rendered.

This coinsurance calculation is consistent with the definition of coinsurance as an amount a member may be required to pay as their share of the cost for services or prescription drugs. The methodology is used for all UnitedHealthcare Medicare Advantage plans nationwide. Ensure you have correct system setup and use consistent coinsurance calculations to help reduce member appeals and complaints.

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
  • Reductions applied to services/claims resulting from 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 

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. If you know or have reason to suspect the member’s benefits do not cover the service, 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.

For MA members, in addition to obtaining the member’s written consent before the service is done, 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.

Submit an advance notification request for a pre-service organization determination on

You should know or have reason to suspect that a service or item may not be covered if:

  • We have provided notice through an article on including clinical protocols, and/or medical policies; 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 preservice organization determination), you may receive an administrative claim denial. You cannot bill the member for administratively denied claims.

Balance Billing

You cannot bill members for covered services beyond their normal cost sharing amounts (copayment, deductible, or coinsurance).

You cannot:

  • Bill,
  • Charge,
  • Collect a deposit,
  • Seek compensation,
  • Seek remuneration,
  • Seek reimbursement, or
  • Have recourse against our members, their representative, or the MA organization.

You must either:

  1. Accept payment made by or on behalf of us as payment in full; or
  2. Bill the appropriate state source for such cost-sharing amount.

Cost-sharing for Qualified Medicare Beneficiary (QMB)

QMBs 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.