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.

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).