Medicare AdvantageAdministrativeMedium impact
Payment of Cost Sharing for Medicare Advantage Plan Members
Illinois Medicaid - HFS·IL·Provider Notice
Effective date
Jul 1, 2009
We identified it
Jun 21, 2026
Summary
This policy clarifies billing procedures for Medicare cost sharing (copayments, deductibles, coinsurance) for QMB and Dual Eligible participants. For most Medicare Advantage plans (HMOs, PPOs, Special Needs), providers must seek cost sharing payment from the managed care plan directly and cannot bill HFS. However, for Medicare Private Fee-For-Service (PFFS) plans, providers can bill HFS for cost sharing using specific claim forms.
Action Required
Immediately: Billing team must verify Medicare plan type for QMB and Dual Eligible participants. For Medicare HMO, PPO, and Special Needs Plans - seek cost sharing payment from the managed care plan only, do not bill HFS. For Medicare PFFS plans - submit HFS 3797 or 837P (non-institutional) or UB04 or 837I (institutional) to HFS for cost sharing reimbursement. Use TPL Code 910 with appropriate TPL Status Code on 837P claims. Ensure claims are within 24-month timely filing limit.