Balance billing

Balance billing is the practice of billing the patient for the difference between what Priority Health pays for covered services and the "retail" price you charge uninsured patients for those services.

Priority Health does not allow participating providers to balance-bill patients for covered services.

Balance billing rules under Medicare

The Medicare Managed Care Manual, Chapter 4, Section 170, states in part: 

Medicare Advantage members are responsible for paying only the plan-allowed cost-sharing (copayments or coinsurance) for covered services.

  • Priority Health as the Medicare Advantage Organization (MAO), not the Medicare member, is obligated to pay limited balance billing amounts to non-par providers; see below.
  • If a member inadvertently pays a bill which is Priority Health's responsibility, we must refund the amount to the enrollee.

Balance billing specifically prohibited for Medicare-Medicaid eligibles

You may not balance bill for services and supplies furnished to Qualified Medicare Beneficiaries (QMBs); for them, Medicaid is responsible for deductibles, coinsurance and copayment amounts for Medicare Part A and B covered services. 

For more information see MLN Matters SE1128.

Note: QMBs are sometimes called "dual eligibles." They are entitled to Medicare Part A, eligible for Medicare Part B, have income below 100% of the Federal Poverty Level, and have been determined to be eligible for QMB status by the State Medicaid Office.