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Section
3.5 Third Party Liability and Coordination of Benefits
3.5.1 Introduction
3.5.2 References
3.5.3 Scope
3.5.4 Did you know…?
3.5.5 Objectives
3.5.6 Definitions
3.5.7 Procedures
3.5.7-A: How do behavioral health providers know if a person has
other health insurance coverage?
3.5.7-B: How do behavioral health providers know what services the
other health insurance party will cover?
3.5.7-C: Billing requirements
3.5.7-D: Discovery of third party liability after services were
rendered or reimbursed
3.5.7-E: Co-payments, coinsurance and deductibles
3.5.7-F: Transportation
3.5.7-G: Medicare Part A and Part B
3.5.7-H: Medicare Part D Prescription Drug Coverage
3.5.1
Introduction
Third party
liability refers to situations in which persons enrolled in the
public behavioral health system also have behavioral health service
coverage through another health insurance plan, or “third party”.
The third party can be liable or responsible for covering some or
all the behavioral health services a person receives. Behavioral
health providers are responsible for determining and verifying if a
person has third party health insurance before using other sources
of payment such as Medicaid (Title XIX), KidsCare (Title XXI) or
State appropriated behavioral health funds.
There
are two methods used in the coordination of benefits; cost avoidance
and post-payment recovery:
- Cost avoidance-Behavioral health
providers must cost avoid all claims or services that are subject
to third-party payment and may deny a service to a person if it is
known that a third party (i.e., other insurer) will provide the
service. However, in emergencies, behavioral health providers must
provide the necessary services and then coordinate payment with
the third party payer. If a third party insurer (other than
Medicare; see subsections 3.5.7-G and H regarding Medicare Part A,
B and D cost sharing responsibilities) requires the person to pay
any co-payment, coinsurance or deductible, the T/RBHA is
responsible for covering these costs for Title XIX/XIX persons.
Non-Title XIX/XXI persons must pay any co-payment, coinsurance or
deductible of the third party insurer.
- Post-payment recovery is necessary
in cases where a behavioral health provider was not aware of third
party coverage at the time services were rendered or paid for, or
was unable to cost avoid.
The intent of this section is to
describe the requirements for behavioral health providers to:
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3.5.2
References
The following citations can serve as additional resources for this
content area:
3.5.3
Scope
To whom does this apply?
All persons seeking enrollment or enrolled in the public
behavioral health system.
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3.5.4
Did you know…?
- If third party information becomes
available to the provider at any time for Title XIX or Title XXI
eligible persons, that information must be reported to the AHCCCS
Administration within 10 days from the date of discovery.
Providers report third party information via the following
website:
https://cmts.hmsy.com/tplreferrals. The T/RBHA is
responsible for making third party payer information available to
all providers involved with the person receiving behavioral health
services.
-
Third parties include, but are not
limited to, private health insurance, Medicare, employment related
health insurance, medical support from non-custodial parents,
court judgments or settlements from a liability insurer, State
worker’s compensation, first party probate-estate recoveries, long
term care insurance and other Federal programs.
-
For those Medicare Part A and Part
B services that are also covered under Title XIX/XXI, there is no
cost sharing obligation if the T/RBHA has a contract with the
Medicare provider and the provider’s contracted rate includes
Medicare cost sharing as specified in the contract.
-
Beginning on January 1, 2006,
Medicare Part D Prescription Drug coverage is available to all
Medicare eligible persons. Medicare is considered third party
liability and should be billed prior to use of Title XIX/XXI or
state funds.
-
Children who qualify for Adoption
Subsidy will be eligible for Title XIX benefits. In addition,
their families may also have private insurance. Simultaneous use
of the private insurance and Title XIX coverage may occur through
the coordination of benefits. Following an intake and assessment,
behavioral health providers must determine the services and
supports needed. Any necessary services that are not covered
through the private insurance, including co-payments and
deductibles, may be covered under Title XIX.
3.5.5
Objectives
To establish guidelines for
behavioral health providers to determine the existence of third
party liability and to coordinate benefits for enrolled persons with
third party liability.
3.5.6
Definitions
Third Party
Liability
Cost avoidance
Dual eligible
QMB dual
Non-QMB dual
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3.5.7
Procedures
3.5.7-A. How do behavioral health providers know if a person has
other health insurance coverage?
Behavioral health providers will inquire about a person’s other
health insurance coverage during the initial intake process (See
Section 3.9, Intake, Assessment and Service Planning). When
behavioral health providers attempt to verify a person’s Title XIX
or Title XXI eligibility, information regarding the existence of any
third party coverage is provided through the automated systems
described in Section 3.1, Eligibility Screening for AHCCCS Health
Insurance, Medicare Part D Prescription Drug Coverage and the
Limited Income Subsidy Program. If a person is not eligible for
Title XIX or Title XXI benefits they will not have any information
to verify through the automated systems, therefore, the existence of
third party payers must be explored with the person during the
screening and application process for AHCCCS health insurance.
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3.5.7-B. How do behavioral health providers know what services the
other health insurance party will cover?
The third party health insurance coverage may cover all or a
portion of the behavioral health services rendered to a person.
Behavioral health providers must contact the third party directly to
determine what coverage is available to the person. At times, T/RBHAs
may incur the cost of co-payments or deductibles for an eligible
person while the cost of the covered service is reimbursed through
the third party payer. Title XIX/XXI funds cannot be used to pay for
cost sharing of Medicare Part D Prescription Drug coverage.
Section
3.21, Service Prioritization for Non-Title XIX/XXI Funding,
describes when Non-Title XIX/XXI funds can be used to pay for
Medicare Part D cost sharing.
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3.5.7-C.
Billing requirements
Upon determination that a person has third party coverage, a
behavioral health provider must submit proper documentation to
demonstrate that the third party has been assigned responsibility
for the covered services provided to the person. For specific
billing instructions, seethe ADHS/DBHS Program Support Procedures
Manual and AHCCCS Billing Manual for IHS/Tribal Providers. The
following guidelines must be adhered to by behavioral health
providers regarding third party payers:
-
ADHS/DBHS and the T/RBHA
must be the payers of last resort for Title XIX/XXI and Non-Title
XIX/XXI covered services. Payment by another state agency is not
considered third party and, in this circumstance, ADHS/DBHS and the
T/RBHA are not the payer of last resort.
-
Benefits must be
coordinated so that costs for services funded by ADHS/DBHS or the T/RBHA
are cost avoided or recovered from a third party payer. Providers
must bill claims for any covered services to any third party payer
when information on that third party payer is available.
Documentation that such billing has occurred must accompany the
claim when submitted for payment. Such documentation includes a copy
of the Remittance Advice or Explanation of Benefits from the third
party payer. The only exceptions to this billing requirement are:
- When a response from the third
party payer has not been received within the timeframe
established by the T/RBHA for claims submission or, in the
absence of a subcontract, within 120 days of submission;
- When it is determined that the
person had relevant third party coverage after services were
rendered or reimbursed; or
- When a behavioral health
recipient eligible for both Medicaid and Medicare (dual
eligible) receives services in a Level I Sub-acute facility that
is not Medicare certified. Non-Medicare certified facilities
should only be utilized for dual eligibles when a Medicare
certified facility is not available.
In an emergency situation, the provider
must first provide any medically necessary behavioral health covered
services and then coordinate payment with any potential third party
payers.
Providers must cost avoid all claims or
services that are subject to third party payment and may deny a
service to a person if they know that the third party payer is
financially responsible for providing the service. If the provider
knows that the third party payer will not pay for or provide a
medically necessary covered service then the provider must not deny
the service nor require a written denial letter. If the provider does
not know whether a particular medically necessary covered service is
covered by the third party payer, they must contact the third party
payer rather than requiring the person receiving services to do so.
Providers must refer to the formulary of the behavioral health
recipients’ Medicare Part D plan to determine if a specific drug will
be covered under Medicare Part D. The Medicare Part D plan formularies
are available at www.medicare.gov. If a drug is not covered by the
behavioral health recipient’s Medicare Part D plan, providers must
follow Section 3.21, Service Prioritization for Non-Title XIX/XI
Funding, to determine if the drug can be covered with Non-Title
XIX/XXXI funds.
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3.5.7-D.
Discovery of third party liability after services were rendered or
reimbursed
If it is determined that a person has third party liability after
services were rendered or reimbursed, behavioral health providers
must identify all potentially liable third party payers and pursue
reimbursement from them. In instances of post-payment recovery, the
behavioral health provider must submit an adjustment to the original
claim, including a copy of the Remittance Advice or the Explanation
of Benefits. Providers may not attempt reimbursement for Title XIX
and Title XXI persons in the following circumstances, unless the
case has been referred to the T/RBHA by AHCCCS and/or ADHS/DBHS:
- Uninsured/under-insured motorist
insurance
- First and third party liability
- Tortfeasors
- Special Treatment Trusts
- Adoptions
- Worker’s compensation
- Estates
The behavioral health provider is
responsible to report any cases involving the above circumstances to
the T/RBHA. Behavioral health providers may be asked to cooperate with
AHCCCS and/or ADHS/DBHS in third party collection efforts. To report,
please contact Gila River RBHA Enrollment and Eligibility Coordinator
at (602) 528-7141.
3.5.7-E. Co-payments, coinsurance and deductibles
If a third-party insurer (other than Medicare; see subsections
3.5.7-G and H regarding Medicare Part A, B and D cost sharing
responsibilities) requires a person to pay a co-payment, coinsurance
or deductible, the T/RBHA is responsible for covering those costs for
Title XIX/XXI persons. Non-Title XIX/XXI persons must pay any
co-payment, coinsurance or deductible of the third party insurer. If a
service is necessary, the provider must ensure that its cost avoidance
efforts do not prevent a person from receiving the service and that
the person will not be required to pay any coinsurance or deductibles
for use of the other insurer’s providers.
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3.5.7-F. Transportation
Behavioral
health providers must provide and retain fiscal responsibility for
transportation for Title XIX and Title XXI persons in order for the
person to receive a covered behavioral health service reimbursed by a
third party, including Medicare.
3.5.7-G. Medicare Part A and Part B
An AHCCCS person may be eligible for both Title XIX and Medicare.
These persons are sometimes referred to as “dual eligibles”. In most
cases, behavioral health providers are responsible for payment of
Medicare Part A and Part B coinsurance and/or deductibles for covered
services provided to dual eligible persons. However, there are
different cost sharing responsibilities that apply to dual eligible
persons for a variety of situations. In the event that a Title XIX
person also has coverage through Medicare, behavioral health providers
must ensure adherence with the requirements described in this
subsection.
Persons who are eligible
for Medicare benefits can receive services through one of the
following arrangements:
- Fee-for-service Medicare system;
or
- Enroll in a Medicare Advantage
Plan.
A Medicare Advantage Plan is a managed
care entity that has a Medicare contract with the Centers for Medicare
and Medicaid Services (CMS) to provide services to Medicare
beneficiaries.
Medicare Part A and Part B cost
sharing responsibilities for persons enrolled in a Medicare Advantage
Plan
ADHS/DBHS is the payer of last
resort. Therefore, if a behavioral health recipient is enrolled with a
Medicare Advantage Plan, the behavioral health recipient must be
directed to their Medicare Advantage Plan. However, if the Medicare
Advantage Plan does not authorize a Title XIX covered behavioral
health service, the [T/RBHA or behavioral health provider] must:
- Review the requested service;
- Determine if the service is a
medically necessary covered service; and
- When determined, provide the Title
XIX covered behavioral health service not covered by Medicare Part A
or B.
[T/RBHA or behavioral health providers]
have cost sharing responsibility for all Title XIX covered services
provided to behavioral health recipients by a Medicare Advantage Plan.
For those Medicare services that have benefit limits, the T/RBHA or
behavioral health provider] must reimburse all Title XIX and Medicare
covered services when the behavioral health recipient reaches the
Medicare Advantage Plan’s benefit limits.
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[T/RBHA or behavioral health providers]
only have cost sharing responsibility for the amount of the behavioral
health recipient’s coinsurance, deductible or co-payment. [T/RBHA or
behavioral health providers] have no cost sharing obligation if the
Medicare payment exceeds the [T/RBHA or behavioral health providers]
contracted rate for the services. The [T/RBHA or behavioral health
provider] liability for cost sharing plus the amount of Medicare’s
payment must not exceed the [T/RBHA’s or behavioral health provider’s]
contracted rate for the service. With respect to co-payments, the [T/RBHA
or behavioral health provider] may pay the lesser of the co-payment or
their contracted rate.
QMB duals enrolled in a Medicare
Advantage Plan
QMB duals are entitled to:
- All Title XIX covered services;
- Medicare Part A covered services;
and
- Medicare Part B covered services.
In addition to Title XIX covered
services, QMB duals may receive Medicare services that are not covered
under Title XIX, or differ in scope or duration. When a behavioral
health recipient is enrolled in a Medicare Advantage Plan, the [T/RBHA
or behavioral health provider] is responsible for cost sharing for
Medicare Part A and Part B services that are not covered under Title
XIX, or differ in scope or duration. These Medicare services include:
- Inpatient psychiatric services
(Medicare has a lifetime benefit maximum);
- Other behavioral health services
such as partial care; and
- Any services covered by or added to
the Medicare Program not covered under Title XIX.
Non-QMB duals enrolled in a Medicare
Advantage Plan
[T/RBHA or behavioral health provider] is responsible for Part A and
Part B cost sharing for Title XIX only covered services for Non-QMB
duals.
Prior authorization for persons
enrolled in a Medicare Advantage Plan
If the RBHA’s contract with a behavioral health provider requires the
behavioral health provider to obtain prior authorization before
rendering services and the behavioral health provider does not obtain
prior authorization, the RBHA is not obligated to pay the Medicare
Part A or Part B cost sharing for Title XIX covered services, except
for emergency services.
If the Medicare Advantage Plan
determines that a service is medically necessary, the [T/RBHA or
behavioral health provider] is responsible for Medicare Part A and
Part B cost sharing, even if the [T/RBHA or behavioral health
provider] determines otherwise. If the Medicare Advantage Plan denies
a service requiring prior authorization for lack of medical necessity,
the [T/RBHA or behavioral health provider] must apply its own
authorization criteria and may not use the Medicare Advantage Plan’s
decision as the basis for denial.
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Out of network services for persons
enrolled in a Medicare Advantage Plan
If an out of network referral is made by a contracted behavioral
health provider and the RBHA specifically prohibits out of network
referrals in the provider contract, then the behavioral health
provider may be considered to be in violation of the contract and the
RBHA has no Part A or Part B cost sharing obligation. The behavioral
health provider who referred the behavioral health recipient to an out
of network provider is obligated to pay any Part A or Part B cost
sharing. The behavioral health recipient must not be responsible for
the Medicare Part A or Part B cost sharing, unless the behavioral
health recipient has been advised of the RBHA’s network and elects to
go out of the network. In this case, the behavioral health recipient
is responsible for paying the Medicare Part A and Part B cost sharing
amount, unless the service is an emergency, pharmacy (not Medicare
Part D) or other physician ordered service.
If the Medicare Advantage Plan and the
RBHA have networks for the same service that have no overlapping
providers and the RBHA chooses not to have the service performed in
its own network, then the RBHA is responsible for Part A and Part B
cost sharing for that service. If the overlapping providers have
closed their panels and the behavioral health recipient goes to an out
of network provider, then the RBHA is also responsible for Part A and
Part B cost sharing.
Medicare Part A and Part B pharmacy
and other physician ordered services for persons enrolled in a
Medicare Advantage Plan
The requirements described under this heading are for information
purposes only. Behavioral health providers may or may not have direct
responsibilities related to these activities.
For purposes of this subsection, “in
the RBHA network” refers to the provider who supplies the
prescription, not the prescribing provider. RBHAs must cover pharmacy
co-payments for medications prescribed by both contracted and
non-contracted providers as long as the prescriptions are filled at a
contracted pharmacy. However, if a provider prescribes a non-formulary
medication, then the RBHA may opt to not reimburse for the
prescription co-payment. If a RBHA requires prior authorization for
formulary medications, then the RBHA may choose not to cover the
co-payment if prior authorization was not obtained.
If a behavioral health recipient
exceeds their pharmacy benefit limit, the RBHA must cover all
prescription costs for the person. These prescriptions are subject to
the RBHA’s formulary, prior authorization and pharmacy network
requirements.
If the Medicare Advantage Plan does not
offer a pharmacy benefit, then the RBHA may require that the
prescribing physician be in the RBHA’s network for prescription
benefit coverage. This requirement extends to all prescribed services
(e.g., laboratory services).
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Cost sharing responsibilities for
persons under the Medicare fee-for-service program
A Medicare beneficiary may
elect to receive Medicare services through providers authorized to
deliver Medicare services. [T/RBHAs or behavioral health providers]
have Part A and Part B cost sharing responsibility for Title XIX
covered services provided to behavioral health recipients by
fee-for-service behavioral health providers in the RBHA’s network. [T/RBHAs
or behavioral health providers] have no Part A and Part B cost sharing
obligation if the Medicare payment exceeds the [T/RBHA’s or behavioral
health provider’s] contracted rate for the services. The [T/RBHA’s or
behavioral health provider’s] liability for Part A and Part B cost
sharing plus the amount of Medicare’s payment must not exceed the [T/RBHA’s
or behavioral health provider’s] contracted rate for the service. For
those Medicare services for which prior authorization is not required,
but are also covered under Title XIX, there is no Part A or Part B
cost sharing obligation if the RBHA has a contract with the provider
and the provider’s contracted rate includes Medicare Part A and Part B
cost sharing as specified in the contract.
QMB duals receiving services under
the Medicare fee-for-service program
QMB duals are entitled to:
- All Title XIX covered services;
- Medicare Part A covered services;
and
- Medicare Part B covered services.
[T/RBHA or behavioral health provider]
is responsible for the payment of the Medicare Part A and Part B
deductible and coinsurance for Title XIX covered services. In addition
to Title XIX covered services, QMB duals may receive Medicare services
that are not covered under Title XIX, or differ in scope or duration.
The services must be provided regardless of whether the behavioral
health provider is in the RBHA’s network. These Medicare services
include:
- Inpatient psychiatric services
(Medicare has a lifetime benefit maximum);
- Other behavioral health services
such as partial care; and
- Any services covered by or added to
the Medicare Program not covered under Title XIX.
Non-QMB duals receiving services
under the Medicare fee-for-service program
[T/RBHA or behavioral health provider] is responsible for the payment
of the Medicare Part A and Part B deductible and coinsurance for Title
XIX covered services that are rendered on a fee-for-service basis by a
Medicare behavioral health provider within the RBHA’s network. [T/RBHAs
or behavioral health providers] are not responsible for Medicare Part
A and Part B services not covered under Title XIX.
Prior authorization for persons
receiving services under the Medicare fee-for-service program
If the RBHA’s contract with a behavioral health provider requires the
behavioral health provider to obtain prior authorization before
rendering services and the behavioral health provider does not obtain
prior authorization, the RBHA is not obligated to pay the Medicare
Part A and Part B cost sharing for Title XIX covered services, except
for emergency services. The RBHA cannot require prior authorization
for Medicare Part A and Part B only services.
If the Medicare provider determines
that a service is medically necessary, the [T/RBHA or behavioral
health provider] is responsible for Medicare Part A and Part B cost
sharing, even if the [T/RBHA or behavioral health provider] determines
otherwise. If Medicare denies a Part A or Part B service requiring
prior authorization for lack of medical necessity, the [T/RBHA or
behavioral health provider] must apply its own authorization criteria.
If the criteria supports the provision of the Part A or Part B
service, the [T/RBHA or behavioral health provider] must cover the
cost of the service.
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Out of network services for persons
receiving services under the Medicare fee-for-service program
If an out of network referral is made by a contracted behavioral
health provider and the RBHA specifically prohibits out of network in
the provider contract, then the behavioral health provider may be
considered to be in violation of the contract and the RBHA has no Part
A or Part B cost sharing obligation. The behavioral health provider
who referred the behavioral health recipient to an out of network
provider is obligated to pay any Part A or Part B cost sharing. The
behavioral health recipient must not be responsible for the Medicare
Part A or Part B cost sharing, unless the behavioral health recipient
has been advised of the RBHA’s network and elects to go out of the
network. In this case, the behavioral health recipient is responsible
for paying the Medicare Part A and Part B cost sharing amount, unless
the service is an emergency, pharmacy (not Medicare Part D) or other
physician ordered service.
Medicare Part A and Part B pharmacy
and other physician ordered services for persons receiving services
under the Medicare fee-for-service program
The requirements described
under this heading are for information purposes only. Behavioral
health providers may or may not have direct responsibilities related
to these activities.
T/RBHAs must cover prescriptions and
other ordered services that are both prescribed and filled by in
network providers. If a provider prescribes a non-formulary
prescription, then the T/RBHA may opt to not reimburse for the
prescription. The T/RBHA may also require prior authorization.
3.5.7-H Medicare
Part D Prescription Drug Coverage
Beginning on January 1, 2006, all persons
eligible for Medicare Part A or enrolled in Medicare Part B are
eligible for Medicare Part D Prescription Drug coverage. Dual eligible
persons (eligible for Medicaid and Medicare) will no longer receive
prescription drug coverage through Medicaid. To access Medicare Part D
coverage, persons must enroll in either a Prescription Drug Plan (PDP
– fee-for-service Medicare) or a Medicare Advantage-Prescription Drug
Plan (MA-PD – managed care Medicare).
Cost sharing responsibilities for
persons in a Medicare Part D PDP or MA-PD
The Medicare Part D Prescription Drug standard coverage (without the
Limited Income Subsidy) includes substantial cost sharing
requirements, which include:
- Monthly premiums averaging $28
- Annual deductible of $250
- Co-insurance of 25% after the
deductible is met up to $2,250 in drug costs
- Co-insurance of 100% from $2,250
through $5,100 in drug costs
- Co-insurance of 5% or co-payments of
$2-$5, whichever is greater, above $5,100 in drug costs
Persons with income below 150% of the
Federal Poverty Limit (FPL) and with resources below $11,500 for an
individual and $23,000 for a couple may be eligible for the Limited
Income Subsidy (LIS) or “extra help” program. With this “extra help”,
all or a portion of the persons’ cost sharing requirements are paid
for by the federal government. Dual eligibles and behavioral health
recipients on a Medicare Savings Program through AHCCCS (QMB, SLMB, or
QI-1) are automatically eligible for the LIS program. Other persons
have to apply for the LIS program. Title XIX/XXI funds are not
available to pay any cost sharing of Medicare Part D. Non-Title
XIX/XXI funds can be used for Medicare Part D cost sharing in
accordance with Section
3.21, Service Prioritization for Non-Title XIX/XXI Funding.
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3.5
Third Party Liability and Coordination of Benefits
Last Revised: 11/08/2005
Effective Date: 06/01/2006 |
