CMS Pub. 100-05, ch. 3, § 10.1

Covered by a Group Health Plan (GHP)

(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

A provider, physician, or other supplier that receives direct payment from the Medicare program

may not charge a beneficiary if the provider, physician, or other supplier has been paid or could

have been paid by a GHP an amount which equals or exceeds any applicable deductible or

coinsurance amount.

EXAMPLE

A Medicare beneficiary who had GHP coverage was hospitalized for 20 days. The hospital's

charges for covered services were $5000. The inpatient deductible had not been met. The gross

amount payable by Medicare (as defined in Pub. 100-05, Chapter 2) for the stay if there had been

no GHP coverage is $4,000. The GHP paid $4,500 ($840 of which was credited to the Medicare

deductible). Medicare will make no payment, since the plan's payment was greater than

Medicare's gross amount payable of $4,000. No part of the $500 difference between the

hospital's charges and the GHP's payment can be billed to the beneficiary since the beneficiary's

obligation, the deductible, was met by the GHP payment. The provider submits a bill to Medicare

reflecting the appropriate amount paid by the primary payer.