Author Topic: CARVE OUT PLANS  (Read 4240 times)

ellie

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CARVE OUT PLANS
« on: May 01, 2010, 12:26:46 PM »
can anyone tell me about carve out plans and if the patient can be billed ?

PMRNC

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Re: CARVE OUT PLANS
« Reply #1 on: May 01, 2010, 01:15:15 PM »
Carve out plans are usually Medicare secondary, the carriers CARVE out what WOULD have been paid by Medicare FIRST. The key words in carve out plans is "What they WOULD have paid"  (had they been primary)

Yes the patient can be billed. Seniors always have a very hard time understanding these type of plans.

here's a more detailed explanation:

Medicare carve out coordination is a concept which requires an explanation.

Under Coordination of benefits, Medicare Carve-Out plans--normally associated with Fortune 1000 companies incorporated in the United States-- are a method of coordinating medical payment pay outs once a retiree becomes eligible for medicare(the 1st day of the month of their 65th birthday) at a money savings to a corporation with limited financial impact to both the corporation and insured. Medicare coordination of benefits by "carve-out" is best explained by an example.

In order for a company to be eligible for "carve-put" coordination of benefits, a company must (in laymen's terms) self insure their employees with monthly collection of premium from their employees to pay for their own health insurance claims.

Claim pay outs for "carve out" plans are paid by the Employer's funds, not a Health Insurance Company's funds. (For instance, Toys R Us employees fund their health insurance claims, Blue Cross Blue Shield doesn't pay, Toys R US's health fund collected from employee's monthly health insurance premium pays.)

"Carve-Out" plans pay after Medicare ONLY after a patient/insured reaches their "Out of Pocket Maximum" or otherwise known as "Stop Loss." "Stop Loss" is any provision within an insurance policy designed to end the insurance company's losses for a claim at a given point.

In an example, say for instance a Toys R Us retiree experiences a $100,000 hospital claim (ei: 2 weeks inpatient hospital claim including 1 week in ICU.) Let's assume this hospital recognizes Medicare with a contract.

Medicare may have a contract with a hospital to pay $61,000 (with a $39,000 write off, non-collectable) & will pay 80% of expenses as the primary insurance carrier(since a patient is retired.) 80% of $61,000=$48,800 paid. The remaining $12,200 ($61,000 Medicare Acceptable minus $48,800 Medicare Paid) is the remaining balance to be paid by the 2nd insurance in line. Under "carve out" plans, the 2nd insurance company to pay (Blue Cross Blue Shield funded by Toys R Us's own fund in this example) will pay AFTER an insured has paid their "Out of Pocket" or "Stop Loss" for the year. If an insured has a $1000 deductible, a "carve out" plan eliminates a deductible's importance and the "out of pocket/stop loss" is the amount that holds importance. Most "Out of Pockets" are approximately $10,000.

Let's assume that Toys R Us retiree hasn't had a previous claim during the year.

$10,000 will be the insured's responsibility to the hospital & Toys R Us's fund through Blue Cross Blue Shield will pay the remaining $2,200. Any future claims for the year will be financially picked up by Toy R Us's funded Blue Cross Blue Shield plan at 100%.
Linda Walker
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blhoffman

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Re: CARVE OUT PLANS
« Reply #2 on: May 01, 2010, 09:00:32 PM »
Carve out can also indicate that a company choose to use a Commercial insurer for all benefits except one or a few that are paid for by another insurance company. These benefits are referred to as carve out.

ellie

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Re: CARVE OUT PLANS
« Reply #3 on: May 02, 2010, 09:50:17 AM »
Medicare paid their allowable. remaining coinsurance due from Aetna is $ 113.53, Aetna paid 96.57 remaining balance from patient is 16.96. sent patient a bill. She states her Aetna should pay 100%, told her to call her insurance company, they called and left a message stating it paid correctly ? I called Aetna and asked if the patient is responsible for this, all they stated was its a carve out plan ???? We are a Ambulatory Surgery Center. Do I tell the patient we do not accept carve out plans this is between her and the insurance company ?
HELP !!

Pay_My_Claims

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Re: CARVE OUT PLANS
« Reply #4 on: May 02, 2010, 02:54:51 PM »
Medicare paid their allowable. remaining coinsurance due from Aetna is $ 113.53, Aetna paid 96.57 remaining balance from patient is 16.96. sent patient a bill. She states her Aetna should pay 100%, told her to call her insurance company, they called and left a message stating it paid correctly ? I called Aetna and asked if the patient is responsible for this, all they stated was its a carve out plan ???? We are a Ambulatory Surgery Center. Do I tell the patient we do not accept carve out plans this is between her and the insurance company ?
HELP !!

1. not all plans pay 100% after Medicare (ie, the deductible/coins)
2. what did the EOB state???
3. Are you a contracted provider?

The plan could have paid at 100% (of their allowed amount). There isn't a way for us to clearly answer the question you pose. You must call Aetna to determine what if anything is billed to the patient. If you don't get a clear answer from the rep...ask for another one or better yet the supervisor. The EOB should state if it is client balance or not.