December 15, 2022

Updates to Medicare estimation process in 2023

Effective Jan. 1, 2023, we’re updating the Medicare estimation methodology we use for fully insured small group and large group businesses. The changes will be as follows:

  • For new fully insured small group businesses, we’ll begin applying the updated Medicare process for members:  
    • Who are eligible for but not enrolled in Medicare Part B
    • For whom Medicare is the primary payer for covered Part B services
  • Note: For renewing small group fully insured businesses, we’ll begin applying the updated methodology on July 1, 2023 (pending approval from state regulators)
  • For large group fully insured businesses, we’ll shift the Medicare estimation methodology from 20% of the billed amount to Medicare allowed, where supported in the member’s certificate of coverage (COC)

What this means for you

You do not need to take any action. We want to tell you about these changes in case your impacted patients have questions.

In the coming months, we’ll contact impacted members to let them know about the increased out-of-pocket costs they could incur starting Jan. 1, 2023, if they do not have Medicare Part B coverage. We’ll encourage these members to visit during the Part B general enrollment period from Jan. 1 – March 31, 2023, to enroll in Part B.

What is Medicare estimation?

Medicare estimation is a standard industry process used to determine the commercial payer’s secondary payment when Medicare is the primary payer, per Medicare Secondary Payer rules, and the member is eligible for but not enrolled in Part B. 

Medicare estimation reduces the plan’s payment for eligible covered benefits by the amount primary Medicare Part B would have paid if the eligible member were enrolled in Medicare Part B. This primary payment that Medicare Part B would have paid is not covered by the fully insured plan. 


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