結餘帳單的事實
什麼是餘額計費？
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.
- 結餘帳單事實概覽
- Billing Protections for People with Medicare and Medi-Cal Video – American Sign Language Interpretation
有哪些例外情況？
雙重合資格受惠人如有以下條件，可獲得醫療服務的賬單：
- D 部分處方藥的自付額；
- 每月分擔未滿足的加州醫療補助健康保健計劃費用；和/或
- 聯邦醫療保險或加州醫療補助健康保健計劃不承保的服務。
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.
提供者應如何為聯邦醫療保險承保的服務計費？
一般來說，聯邦醫療保險將支付聯邦醫療保險費用表的80%。 加州醫療補助健康保健計劃負責任何聯邦醫療保險費用分攤，付款僅限於加州醫療補助健康保健計劃報銷率。 這被稱為「交叉聲明」。 對於原聯邦醫療保險受益人，聯邦醫療保險行政承包商處理聯邦醫療保險付款的主要索賠，然後將索賠轉發給加州醫療補助健康保健計劃計劃，以獲得次級加州醫療補助健康保健計劃。 對於聯邦醫療保險優勢 (MA) 計劃的受益人，醫生應向 MA 計劃收取主要聯邦醫療保險付款，並向加州醫療補助健康保健計劃計劃收取次要加州醫療補助健康保健計劃付款。
提供者無需成為加州醫療補助健康保健計劃網絡的一部分即可處理和支付這些交叉索賠。 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 提供者門戶 to enroll as a Medi-Cal provider or a “Crossover Only” Provider. Please see the DHCS Crossover Billing Toolkit.
如果由醫療保健提供者收取費用，雙重合資格受益人應該怎樣做？
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.
如果提供者不停止帳單收取流程，則雙重合格受益人應立即聯繫其 MA 健康計劃以解決問題，或聯繫 (800) 聯邦醫療保險 ((800) 633-4227)（如果他們參加了 Original）聯邦醫療保險。
如果提供者和健康計劃都無法解決問題，則雙重資格受益人可以致電 (855) 501-3077 聯繫聯邦醫療保險 加州醫療補助健康計劃 索賠專員，詢問下一步要採取哪些行動或聯繫致電加州管理醫療保健部幫助中心(888) 466-2219 提出申訴。
雙重合資格受益人類別
雙重資格包括全面雙重賽和部分雙重賽。
全雙
「完全雙重資格」是指某人同時有資格享受聯邦醫療保險和加州醫療補助健康保健計劃。 擁有完全的雙重資格，意味著您有資格享受加州醫療補助健康保健計劃的全部福利以及聯邦醫療保險。 符合完全雙重資格資格的人，也可以獲得雙重特殊需要計劃（D-SNP）的資格。 這是聯邦醫療保險優勢計劃的一種，提供傳統聯邦醫療保險和醫療補助之外的額外福利。
聯邦醫療保險支付大部分承保護理和福利，但加州醫療補助健康保健計劃支付一些自付費用、共同保險、免賠額和保費。 加州醫療補助健康保健計劃還涵蓋雙重特殊需求計劃未涵蓋的福利，例如長期護理。
部分雙重
「部分雙重資格」是指有資格參加聯邦醫療保險儲蓄專案 (MSP) 但未參加加州醫療補助健康保健計劃的人。 MSP 由每個州的醫療補助專案管理。 雖然 MSP 承擔某些聯邦醫療保險費用，例如聯邦醫療保險 A 部分和 B 部分保費，但具有部分雙重資格的人無法獲得全額醫療補助醫療福利。
其他資源
有關餘額帳單保護的其他資訊可在以下內容找到：