CMS Pub. 100-05, ch. 3, § 10.1.2

Received Primary Payment from a GHP

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

When a beneficiary has been paid by a primary plan, the amount a physician or other supplier

who accepts assignment may collect for Medicare covered services from the beneficiary is

limited to the following:

• The amount paid or payable by the primary plan to the beneficiary. (If this

amount exceeds the amount that is Medicare would pay as primary payer

(without regard to deductible or coinsurance), the physician or other supplier may

retain the primary payment in full without violating the conditions of

assignment.); or

• If the primary payment is less than the applicable Medicare deductible and

coinsurance amounts, the difference between the fee schedule amount (or the

amount the physician is obligated to accept as payment in full, if less), and the

sum of the primary plan’s payment is the Medicare secondary payment.

EXAMPLE

A physician charges $362 for a service. The GHP allows $362 but pays a primary payment

of only $212 because of a $150 plan deductible. The Medicare fee schedule amount is $300.

amount is $300. The amount that Medicare pays as secondary payer is $53.60 since the Medicare secondary

payment amount cannot exceed the amount Medicare would pay primary payer ($300 fee schedule

amount minus the $233 Part B deductible equals $67 x 80 percent = $53.60). The combined primary

payment and Medicare secondary payment is $265.60 ($212 + $53.60).

The physician may charge the beneficiary $34.40, the difference between the Medicare fee

schedule amount ($300) and the sum of the primary payment ($212) plus the Medicare

secondary payment ($53.60). The $34.40 charge to the beneficiary represents the portion of the

Part B deductible and coinsurance amounts in excess of the GHP’s payment. The $233 Part B

deductible is credited in full. The remaining GHP’s payment is applied to the beneficiary's Part B

coinsurance obligation, leaving the beneficiary responsible for the remaining coinsurance

obligation of $34.40.

In the case of non-inpatient psychiatric services, the Part B deductible is credited on the basis of the

Medicare fee schedule amount. There is no annual limit on incurred expenses for non-inpatient psychiatric

services. (See Pub. 100-05, Chapter 2.)