CMS Pub. 100-04, ch. 32, § 360

The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the

42 CFR 424.100-109, Subpart G—Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital.

The Form CMS-1450 or its electronic equivalent must be used.

A. Hospital Filed Claims

1. Inpatient Services

The payment rate for inpatient claims is 100 percent of the nonparticipating provider’s customary charges (see 42 C.F.R.

413.74(b) and 42 C.F.R. 424.104(a)(3)).

The cost of the services is adjusted by any applicable deductible and coinsurance amounts for which the beneficiary is

responsible.

Payment will be made to Federal hospitals that furnish emergency services, on an inpatient basis, to individuals entitled

to hospital benefits. Payment will be based on the lower of the actual charges from the hospital or rates published for

Federal hospitals in the “Federal Register” under Office of Management and Budget - Cost of Hospital and Medical Care

and Treatment Furnished by the United States; Certain Rates Regarding Recovery from Tortiously Liable Third Persons.

Medicare will not pay federal hospitals for emergency items or services furnished to veterans, retired military personnel

or eligible dependents. However, Medicare can pay for the inpatient deductible charged by VA hospitals, or credit that

amount to the Medicare Part A deductible, for emergency services furnished to veterans. If a Part A claim is denied, a

denial notice will be forwarded to the beneficiary from the MAC. The beneficiary can use this notice to forward to their

private insurer, if applicable.

The VA or Department Of Defense hospital must file a statement of election for each calendar year to receive direct

payment from Medicare for all claims filed that year.

2. Outpatient Services

The amount paid by Medicare for emergency outpatient claims is obtained as follows:

• Eighty-five percent of the total covered charges is the estimated cost figure. The applicable Part B deductible

is subtracted. Coinsurance is subtracted from the remainder.

• Subtracting the deductible from 85 percent of the total covered charges and applying the 20 percent

coinsurance rate to the remainder obtains the patient’s coinsurance amount. The hospital will be paid cost

(85 percent of covered charges) minus deductible and coinsurance.

3. Part B Medical and Other Health Services

Part B medical and other health services, including hospital-based ambulance services whether hospital or beneficiary

filed, may be covered and paid on a non-emergency basis. To calculate the amount paid by Medicare, the hospital

subtracts the Part B deductible from the total covered charges and applies the 80 percent payment rate.

4. Special Letters for Partially or Totally Denied (Hospital-Filed) Claims for Emergency Inpatient Services

The patient receives a notice from CMS covering the emergency payment of a partially denied claim. A denial letter and

a Part B explanation of benefits is sent to the patient. The MAC includes its address on this letter.

B. Beneficiary Filed Claim

1. Emergency Inpatient Claims

The payment computation follows:

• Any noncovered accommodation charge is subtracted from the total accommodation charges. The amount of

the inpatient deductible or coinsurance met on this bill is subtracted. Any remainder is multiplied by 60

percent.

• The total noncovered ancillary charge is subtracted from the total ancillary charge. Any inpatient deductible

or coinsurance that remains is subtracted. The remainder is multiplied by 80 percent.

• The benefit amounts obtained are added.

2. Emergency Outpatient Services

To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total

covered charges and apply the 80 percent payment rate.

3. Part B Medical and Other Health Services

Part B medical and other health services furnished by nonparticipating hospitals, including hospital-based ambulance

services, may be covered and paid on a non-emergency basis.

To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total

covered charges and apply an 80 percent payment rate.

4. Special Letters for Patient-Filed Claims for Emergency Inpatient Services

For emergency admissions to nonparticipating hospitals where direct payment is made to the patient, the MAC sends the

beneficiary one of the letters described below, as appropriate.

The letter explains the Part A payments made. Part B payments are made for ancillary services not covered by Part A

and are also explained in a letter. This letter also explains the beneficiary’s right of appeal.

The MAC retains a duplicate of all notices sent for documentation in any appeals process. It enters the date the notice is

released on both copies of all notices.

Sample paragraphs:

• “Enclosed is a check for $______, which is the amount Medicare can pay for inpatient hospital services you

received from (date of admission) to (date of discharge) in (hospital).”

• “Medicare is able to pay 60 percent of the charges for your room and board plus 80 percent of the charges for all

other covered services during the period (date emergency began) to (date payment ended).”

“Medicare is able to pay 60 percent of the charges for your room and board, 80 percent of the charges for other

separately identified charges, and 66 2/3 percent of the other charges which were not separately identified on the

hospital bill.”

• “Medicare does not pay (the first $ ____ of charges) (the first three pints of blood) ($ ____ a day after the 60th

day) in a benefit period. (Select one or more, if applicable.)”

• “If lifetime reserve days are used, add $ ___ a day from ________ to _________.”

• “If you believe your Medicare hospital insurance should have covered all or more of your expenses, you may get

in touch with us at the address shown on this letter.”

• “If you believe that the determination is not correct, you may request a reconsideration for hospital insurance (or

a review for medical insurance). You may make the request by mail to the address shown on this letter. If you

come in person, please bring this notice with you.”

• “This check includes a medical insurance payment for 80 percent of the charges for certain nonroutine hospital

services which you received from _______ through _______. These services are listed on the enclosed form.”

• “If a hospital bill is not itemized, Medicare can pay 66 2/3 percent of the total covered charges. Payment is being

made at this rate for charges from (date emergency began) to (date payment ended).”

• “We are enclosing a check for $ ______. This is your payment under Part B for 80 percent of the charges for the

services which you received from (admission date) through (discharge date) while in (name of hospital). These

services are listed on the enclosed form.”

When payment cannot be made under hospital insurance, medical insurance covers some, but not all, of the hospital

services. Room and board and certain other services are not covered by medical insurance.