CurrentHumanaPolicy CP2022006

Cost-Sharing for Cost-Share Protected Members

Defines Humana's expectations for handling member cost-sharing when members are cost-share protected (e.g., Qualified Medicare Beneficiaries) for Medicare Advantage and Medicaid products; applies to providers submitting claims to Humana.

Policy Summary

PayerHumana

PolicyCost-Sharing for Cost-Share Protected Members

Policy CodePolicy CP2022006

Change TypeClarifiedAdded applicability

Effective DateDec 1, 2022

Next Review Date

Key ActionIf an ERA includes a RARC indicating the member is cost-share protected, providers must not collect the calculated cost-sharing and should review records for any wrongfully collected deductibles.

SourceLink

POLICY UPDATE CHANGES

Humana uses remittance advice remark codes (RARCs) to indicate that members are cost-share protected and provides example language advising providers to review records for wrongfully collected deductibles and bill subsequent payers when appropriate.

Policy explicitly states applicability to Medicare Advantage and Medicaid products.

Medicare Advantage & Medicaidproduct types covered

RARCsmechanism for indicating cost-share protection

QMBexample protected member

Cost-share Protection Coverage Expectations

Cost-share protection handling

Stance on collection of cost-sharing for cost-share protected members and operational guidance for providers when such protection is indicated on remittance advice.

Providers must not collect member cost-sharing for covered services when the member is cost-share protected under federal law (for example, Qualified Medicare Beneficiaries).

Humana will indicate cost-share protection using remittance advice remark codes (RARCs) on electronic remittance advices (ERAs); providers should monitor ERAs and react appropriately when such RARCs appear.

If there is a payer subsequent to Humana, providers may be able to bill that subsequent payer for cost-sharing amounts that cannot be collected from the protected member.

Claims remain subject to other plan requirements such as medical necessity, reasonableness, and applicable referral or authorization requirements despite a member's cost-share protection status.

Policy Summary

PayerHumana

PolicyCost-Sharing for Cost-Share Protected Members

Policy CodePolicy CP2022006

Change TypeClarifiedAdded applicability

Effective DateDec 1, 2022

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required Provider Actions When Cost-share Protection Is Indicated

Note

Action when ERA RARC indicates cost‑share protection

If an ERA includes a RARC indicating the member is cost-share protected, do not collect the calculated cost-sharing from that member. Review your records for any wrongfully collected deductible and, if there is a payer subsequent to Humana, you may bill that subsequent payer for the cost-sharing amount. Monitor Humana ERAs for RARCs indicating cost-share protection and react appropriately when they appear.

Do not collect member deductible, copayment or coinsurance when ERA RARC indicates cost-share protection.
Review records for any wrongfully collected deductible as noted in the example RARC language.
If a subsequent payer exists, bill that subsequent payer for the cost-share amount rather than the protected member.
Monitor Humana electronic remittance advices (ERAs) for RARCs that indicate cost-share protection and take action as directed.

Definitions and Key Terms

Cost-share

DefinitionAny portion of the amount allowed for a covered service that is attributed to deductible, copayment, or coinsurance.

ApplicabilityRepresents member financial responsibility calculated as part of the allowed amount for covered services.

ContextApplies to cost-sharing protections described in this policy (e.g., members protected from collection of cost-share like QMBs).

Electronic Remittance Advice (ERA)

DefinitionAn explanation from a health plan, such as Humana, to a provider about a claim payment.

Delivery formatTypically transmitted electronically to providers as an Electronic Remittance Advice (ERA).

UseIncludes payment details and may include remark codes (RARCs) to indicate special processing such as cost‑share protection.

Qualified Medicare Beneficiary (QMB)

DefinitionA low-income Medicare beneficiary who receives Medicare coverage of Part A and Part B premiums and cost‑sharing.

Protection implicationQMBs are an example of members who may be cost‑share protected under federal law and should not be charged member cost‑sharing for covered services.

RelevanceNamed in this policy as a specific protected member type for Medicare Advantage and Medicaid products.

Remittance Advice Remark Codes (RARCs)

DefinitionAdditional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

PurposeUsed on remittance advices to provide supplementary information about payment adjustments or processing actions.

Operational useHumana uses RARCs on ERAs to indicate cost‑share protection so providers know not to collect protected cost‑sharing amounts.