主页个人余额计费的真相​​ 

关于余额计费的事实​​ 

返回老年人信息​​ 

什么是余额计费？​​ 

Dual eligible beneficiaries (“Medi-Medis”) are individuals with both Medicare and Medi-Cal. Medicare providers (like doctors and hospitals) cannot bill dual eligible beneficiaries for Medicare cost sharing. This is known as balance billing, or “improper billing,” and is illegal under both federal and state law. This means dual eligible beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. Similarly, this protection also applies to Qualified Medicare Beneficiaries (QMBs).​​ 

Dual eligible beneficiaries or QMBs should never receive a bill for Medicare cost sharing.  These beneficiaries should not pay for physician visits and other medical care when they receive Medicare-covered services.  For beneficiaries in a Medicare Advantage plan, including a Medi-Medi Plan, beneficiaries should not pay for medical care when they receive covered services from a provider in their plan’s provider network. This applies to both Medicare and Medi-Cal providers.​​ 

Even if a Medicare provider is not enrolled in Medi-Cal, the provider may not bill the dual eligible beneficiary. Please see additional resources below to learn more about balance billing.​​ 

有哪些例外？​​ 

如果双重合格受益人符合以下条件，则可能会收到医疗服务账单：​​  

  1. D 部分处方药的共同支付；​​  
  2. 未满足的 Medi-Cal 费用的每月分摊费用；和/或​​  
  3. Medicare 或 Medi-Cal 不承保的服务。​​ 

Please note, certain administrative fees, such as for missed appointments or completing a form outside of an appointment, are not prohibited by federal guidance.  However, charges for missed appointments must be the same as that assessed for non-Medicare patients.​​ 

服务提供商应如何为医疗保险覆盖的服务开具账单？​​ 

一般来说，Medicare 将支付 Medicare 费用表的 80%。 Medi-Cal 负责任何 Medicare 费用分摊，且支付限额不超过 Medi-Cal 报销率。 这被称为“交叉索赔”。 对于原始医疗保险的受益人，医疗保险行政承包商将处理医疗保险支付的主要索赔，然后将索赔转发给 Medi-Cal 计划以获得次要的 Medi-Cal 支付。 对于医疗保险优势计划 (MA) 的受益人，医生应向 MA 计划收取主要医疗保险费用，并向 Medi-Cal 计划收取次要 Medi-Cal 费用。​​ 

提供商不需要成为 Medi-Cal 计划网络的一部分来处理和支付这些交叉索赔。​​  However, Medi-Cal plans will pay a physician who is an active Medi-Cal provider or a “Crossover Only” provider any amount owed under state Medi-Cal law. Please access the​​  DHCS PAVE 提供商门户​​  to enroll as a Medi-Cal provider or a “Crossover Only” Provider. Please see the DHCS Crossover Billing Toolkit.​​ 

如果医疗保健提供者向双重合格受益人收费，他该怎么办？​​ 

If a health care provider has billed a dual eligible beneficiary for a Medi-Cal or Medicare covered service, the beneficiary should not pay the bill. Instead, the beneficiary should first try to resolve the issue with their health care provider, to tell them they should not have been billed because they receive both Medicare and Medi-Cal.​​  

Providers must take immediate actions to fix the issue once they know that a beneficiary is dually eligible. The provider must refund any amounts already paid, stop the bill collection process, and work with credit reporting agencies to correct any issues caused by billing dual eligible beneficiaries. Providers can refer to the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN) Matters Article for additional information.​​ 

如果服务提供商不停止账单收集流程，则双重合格受益人应立即联系其 MA 健康计划以解决问题，或联系 (800) MEDICARE ((800) 633-4227)（如果他们已参加原始 Medicare）。​​ 

如果服务提供商和健康计划都无法解决问题，那么双重合格受益人可以致电 (855) 501-3077 联系 Medicare Medi-Cal 监察员，询问下一步应采取什么行动，或致电 (888) 466-2219 联系加州管理医疗保健帮助中心，提出投诉。​​ 

双重合格受益人的类型​​ 

双重资格包括完全双重资格和部分双重资格。​​  

全双打​​ 

“完全双重资格”意味着某人同时具备 Medicare 和 Medi-Cal 的资格。 拥有完全的双重资格意味着您有资格享受完全的州 Medi-Cal 福利以及 Medicare。 符合完全双重资格要求的人也可能符合双重特殊需求计划 (D-SNP) 的资格。 这是一种医疗保险优势计划，提供超出传统医疗保险和医疗补助的额外福利。​​ 

Medicare 支付大部分承保的护理和福利，但 Medi-Cal 支付部分自付费用，包括共付额、共同保险、免赔额和保费。 Medi-Cal 还涵盖双重特殊需求计划未涵盖的福利，例如长期护理。​​  

部分对偶​​ 

“部分双重资格”是指一个人有资格参加医疗保险储蓄计划 (MSP)，但未加入 Medi-Cal。 MSP 由各州的医疗补助计划管理。 虽然 MSP 承担某些医疗保险费用，例如医疗保险 A 部分和 B 部分的保费，但具有部分双重资格的人无法获得完整的医疗补助医疗福利。​​  

其他资源​​ 

有关余额账单保护的其他信息，请参阅：​​