(a) An
insurer shall apply the Medicare payment limitations of Act 6 to provider
services covered by bodily injury liability, uninsured and underinsured
motorists, first-party medical and extraordinary medical benefits coverages
under an automobile insurance policy.
(b) In an action for damages against a
tortfeasor arising out of the maintenance or use of a motor vehicle
75 Pa.C.S. §
1720
(relating to subrogation) applies.
(c) If an insured's first-party limits have
been exhausted, the insurer shall, within 30 days of the receipt of the
provider's bill, provide notice to the provider and the insured that the
first-party limits have been exhausted.
(d) Upon receipt of a provider's bill, the
insurer shall make a determination of the appropriate Medicare payment and pay
up to the first-party benefit limits of the policy. If the determined amount
exceeds the benefit limits of the policy, or the determined amount plus
previously paid benefits exceed the benefit limits of the policy, the provider
may directly bill the insured or a secondary insurance carrier.
(e) If only a portion of the provider's
services are paid by the automobile insurance policy, because benefit limits
have been exhausted, the provider may bill the insured for the remaining
services not paid under the automobile insurance policy. The provider's bill to
the insured shall be limited to the remaining services not paid under the
automobile insurance policy.
Example: Assume an insured has $5,000 of
first-party benefits from the insured's automobile insurance policy and no
health insurance. Further assume the provider's bill totals $10,000 and the
Medicare payment for the $10,000 total bill would be $6,000. The actual worth
of the $5,000 of first-party benefits applied at the appropriate Medicare
payment is $8,333 worth of services of the $10,000 bill ($5,000 is to $6,000 as
x is to $10,000; x is $8,333). The provider may bill the insured $1,677, or
$10,000 less $8,333, for the remaining services not paid under the automobile
insurance policy.
(f) If another
insurance policy exists and a provider bills that insurer for the actual worth
of remaining services not paid (such as $1,667 in the Example in subsection
(e)) that insurer shall determine the appropriate amount of payment to the
provider under the terms of the insured's health or other insurance policy,
without regard to the medical cost containment provisions of the act.
(g) When multiple providers seek
reimbursement and when their bills for services collectively exceed the policy
limits, providers shall be paid by the insurer in the order the insurer
receives a provider's bill. If bills are received simultaneously, the bill with
the lowest payment amount in accordance with §
69.43 (relating to insurer payment
requirements) shall be paid first.
(h) If no portion of the provider's bill is
payable under automobile insurance coverage, the Medicare payment limitations
no longer apply. A provider may directly bill the insured or other insurance
carrier as it has prior to passage of Act 6.
