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088698 1 (1975-10-08)

handle is hein.gao/gaobactzy0001 and id is 1 raw text is: I
















           ~ocial and Rehabilitation Service, R'egioni IT
           S 3').1tme nt of health, Fducation and elfare
      7   25 Federal Plaza
                          wYork 10007

          Pear Tfr. >mith

               On August  1, 1975, we net with Messrs. :illil. Toby and Stanley
          A llen o' your staff to discuss Medicaid overbillIn's by the -elw York
          rity  cal th and `ospitals Corporation (Hitc) for outpatient departmeat
          cLinvic services applicable to individuals; covered under both the
          Mecar and oMdi   caid programs  (dual. beneficiaries). This lotter
            , confirms theC information we supplied at that meeting.

               Outpatient hospital services  are covered under palt a of
             icare,  and assumingc the beneficiary has ret the annual 60
          part  8 deductible, are subject to a 20 percent coinsurance provision
          which is  the6 responi3bility of the beneficiary. The prodram  eim-
          burses the  instituion on the basis of  80 percent of reasonable
          costs, which are sunject to  retroactive audit and adj stment, and
          the  coinsurance portion is usually calculated and collected on the
          basis of  20 percent of the reasonable charges.  For a dual bonefi-
          clary however,  the cinsurence  and deductible anounts are paid by
          ized icai;d.

               The Code of  Pederal Regulations (CFR), Title 45, Parts 249.41(b)
          and  (c)(2), 2   700'O0o)(3) (ii), and 250.31(b) taken to-;ether require,
          _n  effect, that (1) all providers should bill Medicare first, then,
          (2) bill   oicaid  for the coinsurance aund deductibles not covered
          by            m'dicare, and (3) the combined paynents from Medicare and Medicaid
          should not  extceed what would have been paid by the program and the
          beneficiary  under Medicare.  loth the -ureau of liealth Insurance (831)
          P-roran  )fficar, Reidbursiemnt 1Iranch, Peglon 1I, and a SRS Medical
          ervices   Specialist have confirmed these requirements.




                                         So9497

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