II. Medicare
Question 1: Are Medicare co-insurance and deductible payments under a Medigap policy subject to the surcharge provisions? Many carriers provide Medicare supplemental policies to many beneficiaries in New York, including coverage for the Medicare Part A deductible. Are they subject to the 8.18 percent, 24 percent and professional education pool surcharges on services rendered by designated providers?
Question 2: Clarify whether the surcharges apply to revenue a designated provider of services receives for services provided to a patient who is eligible for Medicare.
Question 3: Some Medicare beneficiaries receive coverage for inpatient and outpatient services through a group policy which specifically excludes all those services for which Medicare pays: the so-called Medicare carve out. This situation usually arises when an employee retires and retains coverage through the employer group. Would the insured be the subject of the covered lives assessment, and if so, would this be the case only in situations where the underlying group policy covers inpatient services?
Question 4: If all members of the family, regardless of family size, are eligible for payments as beneficiaries under Medicare, is there a professional education pool charge? Regardless of family size, if all but one of the members of a family are eligible for payments as beneficiaries under Medicare, is the charge for the professional education pool the individual rate?
Question 5: Clarify how the surcharges apply to employer provided health benefits plans for working individuals who are eligible for Medicare payments.
Question 1: Are Medicare co-insurance and deductible payments under a Medigap policy subject to the surcharge provisions? Many carriers provide Medicare supplemental policies to many beneficiaries in New York, including coverage for the Medicare Part A deductible. Are they subject to the 8.18 percent, 24 percent and professional education pool surcharges on services rendered by designated providers?
Answer 1: Where a payor is making payments to a designated provider of service as a result of providing coverage for Medicare coinsurance and/or deductibles, surcharges do not apply because the payor is not considered to be acting as a "non-Medicare" payor. Where a payor is making payments to a designated provider of service as a result of a person's exhaustion of Medicare benefits, or lack of Medicare benefits for a particular service, such payor shall be subject to all applicable surcharges because the payor is considered to be acting as a "non-Medicare" payor. Which specific surcharges apply is dictated by whether the payor has voluntarily elected to pay the Department's pool administrator directly and whether the payor is subject to professional education pool surcharges.
|top|Question 2: Clarify whether the surcharges apply to revenue a designated provider of services receives for services provided to a patient who is eligible for Medicare.
Answer 2: It is important to distinguish surcharge treatment between Medicare Part A and Part B eligibility. Generally, Medicare Part A benefits are automatically available to all persons over age 65. For patients eligible for payments as a beneficiary under Medicare Part A, the applicability of the surcharges follows the same rules delineated in the response to the previous question.
Medicare Part B coverage, on the other hand, is optional on the part of the individual. The individual must apply and pay premiums in order to be eligible for payments as a beneficiary under Medicare Part B. For individuals who enroll, the applicability of the surcharges follows the same rules delineated in the response to the previous question. For individuals not enrolled in Medicare Part B, the surcharges apply in full to any related charges and are based on the election decision of the payor.
|top|Question 3: Some Medicare beneficiaries receive coverage for inpatient and outpatient services through a group policy which specifically excludes all those services for which Medicare pays: the so-called Medicare carve out. This situation usually arises when an employee retires and retains coverage through the employer group. Would the insured be the subject of the covered lives assessment, and if so, would this be the case only in situations where the underlying group policy covers inpatient services?
Answer 3: Countable persons for purposes of covered lives assessment calculations never include persons who are eligible for payments as beneficiaries under Medicare. Further, countable persons only include persons with inpatient coverage.
|top|Question 4: If all members of the family, regardless of family size, are eligible for payments as beneficiaries under Medicare, is there a professional education pool charge? Regardless of family size, if all but one of the members of a family are eligible for payments as beneficiaries under Medicare, is the charge for the professional education pool the individual rate?
Answer 4: Regardless of family size: (1) in any family where all persons are eligible for payments as beneficiaries under Medicare, there is no covered lives assessment liability and (2) in any family where all but one person is eligible for payments as beneficiaries under Medicare, the individual assessment applies.
|top|Question 5: Clarify how the surcharges apply to employer provided health benefits plans for working individuals who are eligible for Medicare payments.
Answer 5: Pursuant to the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and the Deficit Reduction Act of 1984 (DEFRA), federal mandates, some privately insured employee health benefits plans for working Medicare eligible individuals are required to make patient service payments before Medicare. However, in such instances, the private insurer does not have a surcharge liability, unless the service is an otherwise uncovered Medicare service or where there is an exhaustion of Medicare benefits.
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