Section 29-4813. INPATIENT SERVICES: THIRD PARTY LIABILITY AND PATIENT COST-SHARING

 

4813.1 For Medicaid reimbursement of inpatient hospital discharges, DHCF shall calculate the allowed amount for a service and then subtract third party liability (TPL) and patient cost-sharing in determining the actual payment to the provider. 

 

4813.2 DHCF shall consider a beneficiary to have TPL when the individual receives health care benefits from organizations such as Medicare, commercial health insurance companies, prepaid health plans, health maintenance organizations, and other benefit plans. 

 

4813.3 Where a commercial payer or some other third party (except Medicare) is liable for some portion of the claim, that portion shall be subtracted from the allowed amount.

 

4813.4 Patient cost-sharing shall relate to any portion that may be due from the patient such as coinsurance, deductibles, or spend-down payments. The cost-sharing amount shall be subtracted from the allowed amount. 

 

 

authority

An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2014 Repl.& 2015 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).

source

Final Rulemaking published at 45 DCR 4141, 4151 (June 26, 1998); as amended by Emergency and Proposed Rulemaking published at 57 DCR 2691 (March 26, 2010) [EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 57 DCR 6837 (July 10, 2010) [EXPIRED]; as amended by Final Rulemaking published at 58 DCR 4323, 4332 (May 20, 2011); as amended by Final Rulemaking published at 59 DCR 15078 (December 28, 2012); as amended by Final Rulemaking published at 63 DCR 5234 (April 8, 2016).