Charging members - Chapter 11, 2022 UnitedHealthcare Administrative Guide

Annual individual and family out-of-pocket maximums are equal to the combined total of deductible, copayment and coinsurance amounts the member pays as shown on their 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 individual or family out-of-pocket maximums. Refer to the member’s Schedule of Benefits to determine if a cost-share amount, for a particular covered service, applies to the member’s annual individual and/or family out-of-pocket maximums.

When an individual member’s out-of-pocket expenses have reached the individual out-of-pocket maximum, the member will not have any additional cost-share for services that apply to the annual individual out-of-pocket maximum for the rest of that plan year.

When a family’s out-of-pocket expenses have reached the annual family out-of-pocket maximum, the family members will not have any additional cost-share for services that apply to the annual family out-of-pocket maximum for the rest of that plan year.

Some services may not be covered until the member meets the annual individual deductible. Only amounts incurred for covered services that are subject to the annual individual deductible will count toward the annual individual deductible. Benefit plans may have an annual individual deductible only or both an annual individual and annual family deductible. No further deductible will be required for any individual family member when the individual deductible amount has been satisfied for the rest of the plan year. For plans with both annual individual and family deductibles, no further deductible will be required from any covered family member for the rest of the plan year when the annual family deductible has been met.

As previously indicated, only certain covered services apply to the annual individual and family deductibles. Covered services that do not apply to the annual individual and family deductibles may incur a member cost-share that is considered separate from, and not included in, the annual individual and family deductibles. The annual individual and family deductibles apply to the annual individual and family out-of-pocket maximums. The amounts applied are based upon UnitedHealthcare’s contracted rates, copayments and coinsurance.

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 (EOC).

Cost-sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Refer to the member’s EOC 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 is defined as amounts paid by the member such as copayments, coinsurance and deductibles according to their plan benefits.

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 health 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 the amount a member pays as their share of the cost for services or prescription drugs. The methodology is used for all UnitedHealthcare MA plans nationwide. Ensure you have the correct system setup and use consistent coinsurance calculations to help reduce member appeals and complaints.

Do not charge additional fees for:

• Covered services beyond their copayments, coinsurance or deductible.
• Retainers or administrative fees.
• Services/claims that were denied 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).

Concierge/boutique medical practices charge members a service fee in exchange for longer visits, a commitment from the practices for shorter wait times or, in many cases, access to the provider’s cell phone number and email address to get in touch with their health care provider quickly.

We will allow our contracted network providers to charge concierge/boutique medicine fees with the following restrictions:

• You must give members the choice of paying the concierge membership fee; if the member chooses not to pay the fee, the member may continue seeing your medical practice.
• You must be transparent with the member about what they will receive as part of the concierge membership and fees.
• If you cannot meet the criteria because you are requiring all members to pay the fees, you will need to consider changing your concierge program to comply with our requirements or you will be terminated from our network.
• We must have the opportunity to review and approve the services included with the concierge membership fee. The concierge services should not consist of any covered services that are already included in your Participation Agreement with us.

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 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.
• 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, 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 issued to a MA member is clear that a service or item is not covered.

Use our Provider Authorization and Notification (PAAN) tool in the UnitedHealthcare Provider Portal to submit an advance notification request. The PAAN tool does not issue denials. It tells you if a procedure code requires a review or not. For more information, go to uhcprovider.com/paan.

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 uhcprovider.com including clinical protocols, and/or medical policies.
• 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 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.
• 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.
2.  Bill the appropriate state source for such cost-sharing amount.

Dual-eligible members qualify for both Medicare and Medicaid. If you are a participating health care provider in our MA network, you cannot refuse to see these members. For dual-eligibles for whom the state is responsible for covering Medicare cost-sharing, our contract requires that you accept payments made by or on behalf of our MA plans for covered Part A and B services as payment in full. You can bill the appropriate state Medicaid source for the balance.

QMBs are not responsible for Medicare cost-sharing under CMS regulations. Medicare cost-sharing includes the deductibles, coinsurance and copays associated with covered Part A and B services included under MA plans. You cannot bill, charge, collect a deposit from or 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.