MiSalud as Secondary Payer to Medicare Sample Clauses

MiSalud as Secondary Payer to Medicare. 22.5.1 In general, as provided in Section 7.12 of this Contract, save for services offered by Medicare Platino plans which operate independently of this Contract, MiSalud does not duplicate coverage provided by Medicare to Dual Eligible Beneficiaries and the Contractor shall not be a secondary payer for services for which Medicare is liable. 22.5.1.1 However, in a situation in which a Covered Service is covered in whole or part by both Medicare and MiSalud (for example, hospitalization services for a Dual Eligible Beneficiary who is enrolled in Medicare Part A only and whose hospitalization costs exceed the Medicare limit, per Section 7.12. 1.1.1 of this Contract), the Contractor shall determine liability as a secondary payer as follows: 22.5.1.1.1 If the total amount of Medicare’s established liability for the services (Medicare paid amount) is equal to or greater than the negotiated contract rate between the Contractor and the Provider for the services, minus any MiSalud cost-sharing requirements, then the Provider is not entitled to, and the Contractor shall not pay, any additional amounts for the services. 22.5.1.1.2 If the total amount of Medicare’s established liability (Medicare paid amount) is less than the negotiated contract rate between the Contractor and the Provider for the services, minus any MiSalud cost-sharing requirements, the Provider is entitled to, and the Contractor shall pay, the lesser of: 22.5.1.1.2.1 The Medicaid cost-sharing (deductibles and coinsurance) payment amount for which the Dual Eligible Beneficiary is responsible under Medicare, and 22.5.1.1.2.2 An amount which represents the difference between (1) the negotiated contract rate between the Contractor and the Provider for the service minus any MiSalud cost-sharing requirements, and (2) the established Medicare liability for the services.