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., QMBs) for Medicare Advantage and Medicaid products; directs providers on remittance advice indicators and billing to subsequent payers when applicable.

Policy Summary

PayerHumana

PolicyCost-Sharing for Cost-Share Protected Members

Policy CodePolicy CP2022006

Change TypeNo material change

Effective DateDec 1, 2022

Next Review Date

Key ActionWhen an ERA includes a Remittance Advice Remark Code indicating the member is cost-share protected, providers must not collect cost-sharing from that member and should review records for any wrongfully collected amounts; amounts may be billed to a subsequent payer.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage & MedicaidProducts to which this policy applies

RARCsMechanism to notify providers

QMBProtected beneficiary example

Cost-sharing Protection Rules

Cost-sharing handling rules

Stance on collection of member cost-sharing for cost-share protected members and handling of remittance indications:

Providers must not collect calculated cost-sharing (deductible, copayment, coinsurance) from members who are cost-share protected under federal law.

Humana uses Remittance Advice Remark Codes (RARCs) on Electronic Remittance Advice (ERA)/Remittance Advice (RA) to indicate that a member is cost-share protected; providers should monitor ERA/RA for these RARCs and take appropriate action.

If an ERA/RA includes a RARC indicating cost-share protection, providers should review records for any wrongfully collected deductible or other cost-sharing and, when applicable, bill a subsequent payer rather than the protected member.

Claims remain subject to plan requirements such as medical necessity, reasonableness, and applicable referral or authorization rules; this policy does not by itself determine coverage under a member's specific plan.

Policy Summary

PayerHumana

PolicyCost-Sharing for Cost-Share Protected Members

Policy CodePolicy CP2022006

Change TypeNo material change

Effective DateDec 1, 2022

Next Review Date

SourceLink

On This Page

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Required Provider Billing Actions

Note

Do not collect cost-sharing when ERA RARC indicates protection

When a Humana ERA includes a Remittance Advice Remark Code indicating the member is cost-share protected, do not collect the member's calculated cost-sharing (deductible, copayment, coinsurance). Review your records for any wrongfully collected deductible and, when a subsequent payer exists, consider billing that subsequent payer for amounts you cannot collect from the protected member.

Do not collect calculated cost-sharing from members identified as cost-share protected on the ERA.
Review records for any wrongfully collected deductible as indicated by the RARC.
If there is a payer subsequent to Humana, you may bill that subsequent payer for amounts not collectible from the protected member.

Key Terms

Cost-share — definition and brief explanation

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

ContextCost-share represents member financial responsibility components of a claim (deductible, copayment, coinsurance).

Policy implicationProviders must not collect calculated cost-sharing from members who are cost-share protected under federal law (see QMB note).

Electronic Remittance Advice (ERA) — definition and role

DefinitionAn explanation from a health plan, such as Humana, to a provider about a claim payment (Electronic Remittance Advice, ERA).

RoleERAs convey payment details and remittance codes; providers should monitor ERAs for RARCs indicating cost-share protection.

ActionWhen an ERA includes a RARC indicating cost-share protection, providers should review records for wrongfully collected amounts and not collect from the protected member.

Qualified Medicare Beneficiary (QMB) — definition and note about provider collection prohibition

DefinitionA low-income Medicare beneficiary who receives Medicare coverage of Part A and Part B premiums and cost-sharing (Qualified Medicare Beneficiary, QMB).

ProtectionQMBs are cost-share protected under federal law; providers must not collect calculated cost-sharing from QMB members.

Subsequent payer noteIf there is a payer subsequent to Humana, providers may bill that subsequent payer for amounts that cannot be collected from the protected member.

Remittance Advice Remark Codes (RARCs) — definition and use

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

UseHumana uses RARCs on ERA/RA to indicate when members are cost-share protected; a sample RARC alerts providers to review for wrongfully collected deductibles and that amounts may be billed to a subsequent payer.

Provider actionProviders should note RARCs on ERAs and react appropriately, including not collecting cost-share from protected members and pursuing subsequent payers when applicable.

OpenPayer

Cost-Sharing for Cost-Share Protected Members

Cost-sharing Protection Rules

Remittance Remark Codes

Required Provider Billing Actions

Key Terms