Page 11 - Medicare Benefit Policy Manual

Medicare pays $1,000, which is less than the gross amount payable by Medicare minus
the Medicare deductible ($3,350 - $812 = $2,538). The beneficiary’s Part A deductible is
met by the VA payment.

50.1.3 - Effect of VA Payments on Medicare Deductible and Utilization
(Rev. 1, 10-01-03)
A3-3153.1.D, HO-260.3.B

Where an authorization issued by the VA binds the VA to pay in full for the items and
services, no payment may be made under Medicare. When the VA pays in full, the
services do not count against benefit maximums, e.g., the 90 days of inpatient hospital
services or the 60-day lifetime reserve. Charges which would be reimbursable by
Medicare except for the fact that the VA paid in full for authorized services may be
credited to the Medicare deductibles.

When the VA authorizes fewer days than the total number of covered days in the stay,
Medicare utilization is determined as follows:

• Divide the actual Medicare payment by the amount Medicare would have paid for
covered charges as primary payer (i.e., the gross amount payable by Medicare for
all covered days in the stay reduced by applicable Medicare deductible and
coinsurance).

• Multiply this percentage by the number of covered days in the stay.

A partial day resulting from this calculation is not charged as a full day if it is less than .5
of a day, but is charged as a full day if it is .5 or more of a day.

EXAMPLE: The following is the same facts as presented in example in §50.1.2. The
amount Medicare would pay, as a primary payer, is $2,538 ($3,350 - $812 deductible).
Utilization is determined as follows: $1,000 ÷ $2,538 =. 39 X 7 days = 2.75, rounded to
3 days.

When the VA pays an amount for Medicare covered services that is equal to, or less than,
the deductible and coinsurance that would apply if Medicare were the primary payer,
utilization is not reduced.

50.1.4 - VA “Fee Basis Card”
(Rev. 1, 10-01-03)
B3-2309.2

1. General

One method the VA uses to authorize physician services is to issue the veteran a “fee
basis ID card” (formally designated the VA Outpatient Medical Treatment Information
Card). This card is issued to certain veterans with a service connected disability, as well