Page 10 - Medicare Benefit Policy Manual

pays secondary benefits to the beneficiary for VA copayment amounts in accordance with
§§50.1.4.

The charges for the following services are credited to the Medicare deductibles, on the
basis of Medicare fee schedule or allowable amounts, even though the Federal Agency
(VA) has not yet paid for them.

• Charges for services that exceed the VA copayment;

• Services rendered in a non-VA facility that are not authorized by the VA; or

• Services rendered after VA benefits are exhausted in a non-VA facility.

Crediting of VA payments to Medicare deductibles is handled in the same manner as the
crediting of employer group health plan payments. See Pub 100-05, the Medicare
Secondary Payer (MSP) Manual, Chapter 3, for billing and Chapter 5 for payment
instructions. Medicare can pay for such services where neither the physician/supplier nor
beneficiary has claimed benefits from the VA.

Medicare may also pay for (covered) services for which the VA does not make any
payment. For example, if a veteran is authorized “fee basis” care at VA expense for a
service connected back injury, and receives treatment for a different condition for which
the VA does not pay, Medicare can pay for the (covered) services that are not
reimbursable by the VA.

50.1.2 - Medicare Secondary Payment Where VA Authorizes Fewer
Days Than Total Number of Covered Days in the Stay
(Rev. 1, 10-01-03)
A3-3153.1.C, HO-260.3.B

The Medicare secondary payment is the lower of:

• The gross amount payable by Medicare for all covered days in the stay (without
regard to deductible or coinsurance) minus the amount paid by the VA for
Medicare covered services, or

• The gross amount payable by Medicare (without regard to deductible or
coinsurance) minus any applicable Medicare deductible or coinsurance.

EXAMPLE: The VA authorizes payment for 4 days of a 7-day stay. Charges for the 4
days total $2,350. The VA reimburses the hospital that amount. The gross amount
payable by Medicare (unreduced by deductible and coinsurance) for the 7-day stay is
$3,350. The beneficiary’s Part A deductible has not been met. The Medicare secondary
payment is determined by subtracting the VA payment from the gross amount payable by
Medicare: $3,350 - $2,350 = $1,000.