STATEMENTS OF POLICY
Title 55--PUBLIC WELFARE
DEPARTMENT OF PUBLIC WELFARE
[55 PA. CODE CH. 1101]
Payment in Full
[29 Pa.B. 5622] Purpose
The purpose of this statement of policy is to remind providers of the legal prohibition of seeking or requesting supplemental or additional payments from recipients for covered services.
Scope
This statement of policy is applicable to all providers enrolled in the Medical Assistance (MA) Program.
Background/Discussion
In a recent State Medicaid Director letter, the Health Care Financing Administration alerted States of incidents where providers required Medicaid recipients to make cash payments for Medicaid covered services and refused to provide medically necessary services to a Medicaid recipient for lack of prepayment for these services. These practices are illegal and contrary to the participation requirements of Pennsylvania's MA Program and MA provider's responsibility to assure delivery of all compensable medically necessary services to MA recipients.
The following examples illustrate this issue:
1. The Department of Public Welfare denies payment to an MA participating provider because the provider failed to submit the original or initial invoice within 180 days of the date of service. The provider is prohibited from seeking payment from the MA recipient.
2. An MA participating provider treats a dually eligible recipient. The Medicare payment (80% of the reasonable and customary charge) is equal to or greater than the MA fee. The provider has been ''paid in full'' and cannot seek reimbursement from the MA recipient for the coinsurance or deductibles.
3. An MA participating provider tells his patient that MA does not pay enough and indicates that he will treat the MA recipient as a private pay patient. The provider charges the recipient a supplemental fee of $20 for each office visit. This arrangement is illegal.
4. A network provider treats a HealthChoices member, who also has other commercial insurance, for an MA covered service. The commercial insurance payment, less copayment, is equal to the HealthChoices plan's charge for this service. The network provider may not bill the member for the copayment.
Effective Date
This statement of policy takes effect upon publication in the Pennsylvania Bulletin.
FEATHER O. HOUSTOUN,
Secretary(Editor's Note: The regulations of the Department, 55 Pa. Code Chapter 1101, are amended by adding a statement of policy in § 1101.63a (relating to full reimbursement for covered services rendered--statement of policy).)
Fiscal Note: 14-BUL-057. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1101. GENERAL PROVISIONS
FEES AND PAYMENTS § 1101.63a.
Full reimbursement for covered services rendered--statement of policy. (a) Section 1406(a) of the Public Welfare Code (62 P. S. § 1406(a)) and MA regulations in § 1101.63(a) (relating to payment in full) mandate that all payments made to providers under the MA Program plus any copayment required to be paid by a recipient shall constitute full reimbursement to the provider for covered services rendered.
(b) A provider who seeks or accepts supplementary payment of another kind from the Department, the recipient or another person for a compensable service or item is required to return the supplementary payment.
(c) A provider may bill an MA recipient for a noncompensable service or item if the recipient is told before the service is rendered that the program does not cover it.
[Pa.B. Doc. No. 99-1832. Filed for public inspection October 29, 1999, 9:00 a.m.]
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