Balance Billing FAQ
Sunshine Health works to ensure that our Medicare, Medicaid and CMS members are never inappropriately billed or held financially liable for the care they receive. Please review the questions and answers below. Remember, providers cannot engage in balance billing of Medicare, Medicaid and CMS Health Plan beneficiaries.
Balance billing occurs when a participating provider bills a member for fees and surcharges above and beyond a member’s copayment and coinsurance responsibilities for services covered under the member’s benefit program, or for claims for services denied by Sunshine Health or the affiliated participating provider.
No. Balance billing is strictly prohibited by state and federal law and in accordance with the Sunshine Health Provider Participation Agreement (PPA). Federal law also does not allow providers to collect Medicare Parts A and B deductibles, coinsurance or copayments from members enrolled in the qualified Medicare beneficiaries (QMB) program, which exempts members from Medicare cost-sharing liability. Participating providers are prohibited from initiating or threatening to initiate a collection action against a member for nonpayment of a claim for covered services. Participating providers agree to accept Sunshine Health’s fee for these services as payment in full, except for applicable copayments, coinsurance or deductibles.
Participating providers may bill a member for non-covered services when the member is notified in advance that the services to be provided are not covered and the member nonetheless requests in writing that those services be rendered. This agreement must be signed by the provider and member and kept in the member’s file. After verifying that a patient is eligible for Medicaid, the provider must inform the member that they are responsible for paying for any service rendered that is not covered by Medicaid. The provider must discuss this with the member for each service provided and must document this discussion in writing in the medical record.
Participating providers who exhibit a pattern and practice of inappropriately billing members will be contacted by Sunshine Health and subject to disciplinary action.
This prohibition applies to all Medicare, Medicaid and CMS Health Plan providers, not just those who accept Medicaid. In addition, balance billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full amount of Medicare cost-sharing.
Yes. In accordance with standards established by the Centers for Medicare & Medicaid Services (CMS), under the terms of the PPA, participating providers agree to hold the member harmless and protect the member from incurring financial liabilities that are the legal obligation of a Managed Care Organization or its participating providers. In no event, including but not limited to, nonpayment, termination, nonrenewal, insolvency, or breach of an agreement by Sunshine Health, can the provider or any intermediary bill, charge, collect a deposit from, or receive other compensation or remuneration from a member. Participating providers cannot take any recourse against a member, or a person acting on behalf of a member, for services provided. This provision does not prohibit the following:
- Collection of applicable coinsurance, deductibles or copayments, as specified in the member’s Evidence of Coverage (EOC).
- Collection of fees for non-covered services, provided that the member was informed in advance and in writing of the cost and elected to have non-covered services rendered.
Please reach out to Provider Services at 1-844-477-8313 Monday through Friday from 8 a.m. to 8 p.m. Eastern.