Medicare+Choice program for Medicare enrollees in Managed Care Plans

Although this provision related to balance billing to patients who obtain services from non-contracted suppliers is not new, the issue continues to a confusing one for laboratories.

• Effective 1/1/99, the total payment obligation of a non-contracted Medicare HMO and its Medicare enrollees is limited to the Medicare fee schedule amount.
• When services are performed as a non-contracted or out of network laboratory for a Medicare enrollee of a Medicare HMO, the lab can only collect the Medicare fee schedule amount.
• If the non-contracted plan pays the lab less than the fee schedule amount, the lab can bill the patient the differenc between what the plan pays and the Medicare fee schedule amount for the test.
• If the non-contracted plan does not pay for the service and Medicare does not pay for the service based upon their fee shedule, then the patient cannot be billed.