Members are only responsible for copayments, deductibles and coinsurance. You may 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 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 have 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-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.
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.
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 reach 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 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. 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 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:
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 Medicare Advantage 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:
You may charge members for:
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:
For MA members, in addition to obtaining the member’s written consent before the service is done, you must do the following:
Use our Provider Authorization and Notification (PAAN) tool on UHCprovider.com/paan 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.
You should know or have reason to suspect that a service or item may not be covered if:
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 must either:
Dual-eligible members qualify for both Medicare and Medicaid. If you are a participating care provider in our Medicare Advantage (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.
Qualified Medicare Beneficiaries (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, 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.