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Back  RFI # 1528: Medicare Supp Deductable

Formal vs. Informal Help Informal Formal

Submitter

Carter Mark

Description

We’d like to confirm that we are properly reporting deductibles in Medicare Supplement policies that may or may not pay the Medicare Deductibles.

When the policy pays Medicare deductibles we report:
EB*1*IND*30*MH*MEDICARE SUPPLEMENT - FOLLOWS MEDICARE GUIDELINES~
EB*C*IND*1***29*0~
MSG*THIS POLICY PAYS FOR MEDICARE PART A DEDUCTIBLE~

When the policy does not pay Medicare deductibles we report:
EB*1*IND*30*MH*MEDICARE SUPPLEMENT - FOLLOWS MEDICARE GUIDELINES~
EB*C*IND*1***29*140~
MSG*NO COVERAGE FOR MEDICARE PART B DEDUCTIBLE~

Is this correct?

Response

Additional clarifying information was requested of the submitter and is as follows:

We are trying to understand how to report the Benefit provided or not provided in a policy that supplements Medicare. Specifically, how to report when a Medicare Supplement policy does and does not pay the Medicare deductibles. These policies do not have deductibles of their own. Most of these policies do pay the Medicare deductible. For instance if the policy does pay the Medicare Part B deductible it results in a benefit equal to that deductible. So is that reported as a 0 deductible like below, or how would we report that the policy pays $140 of what was the Medicare deductible?

EB*C*IND*1***29*0~
MSG*THIS POLICY PAYS FOR MEDICARE PART A DEDUCTIBLE~

Or in the case where the policy does not pay the Medicare deductible and it would ultimately become the patient’s responsibility, do we report that as follows?

EB*C*IND*1***29*140~
MSG*NO COVERAGE FOR MEDICARE PART B DEDUCTIBLE~

Policies that are secondary to Medicare and cover benefits that are not covered or not fully covered by Medicare are generally reported as Medigap policies and are identified in EB04 as “MH” (Medigap Part A) or “MI” (Medigap Part B). Unless there is a specific plan or product name associated with the Medigap Policy, EB05 must not be used. EB04 should be used for each EB loop to make it clear that the benefits returned apply to the Medigap policy.

If this policy covers the Medicare deductible amount, it is not reported as a deductible in the supplemental payer’s 271 response. Likewise, you would not report Medicare’s co-payments and coinsurance amounts. Deductible, copayment and coinsurance amounts returned in the 271 are the portion of the patient’s financial responsibility for the plan being returned, not the amount associated with another policy. Therefore the examples provided are incorrect as they are communicating the beneficiary’s Medicare responsibility as a deductible of this. See section 1.4.7.1 271 item 6 which identifies what is and is not to be returned for other plans.

The correct way to report this type of coverage would be:

EB*1*IND*30*MH~
DTP*…~ (Plan date(s) if not already reported in 2100C)
MSG*PAYS FOR MEDICARE PART A DEDUCTIBLE~
Or
MSG*DOES NOT PAY FOR MEDICARE PART A DEDUCTIBLE~
(Depending on if the policy pays or does not pay for the deductible)
Submission 2/21/2012
Status Date 5/22/2012
Status F - Final
Primary References
Document 005010X279
SectionSegment
Set ID271
Loop2110C