General Medicare
- What is the Medicare Summary Notice(MSN)? (04/01/04)
The MSN, a statement Medicare sends to beneficiaries, summarizes all of your inpatient and outpatient claims information processed by the Medicare Contractor over a 31-day period. - How long should I wait before contacting the Medicare carrier to check on the status of a claim? (08/16/07)
If you are not due a payment check from Medicare, your Medicare Summary Notices (MSN) will now be mailed to you on a quarterly basis. You will no longer receive a monthly statement in the mail for these types of MSNs. You will now receive a statement every 90 days summarizing all of your Medicare claims. You may receive a bill from your provider before you receive an MSN. You may not be able to wait for your MSN before your payment to your provider is due. If you have any questions about the bill from your provider, you should call your provider. - What is a "participating provider"? (04/01/04)
Participating physicians are health care providers that have entered into a contract with the Medicare Part B program. The contract states he/she must accept the Medicare Part B approved amount as payment in full for services provided. Medicare Part B will usually pay 80% of the approved amount. The remaining 20%, called coinsurance, is your responsibility. Most Medicare supplement insurance plans will help pay the 20%. - What if a provider does not accept assignment of a
Medicare claim? (01/27/05)
Physicians who do not accept assignment may charge more than Medicare's approved amount but not more than the limiting charge. They also may collect full payment directly from the patient at the time of service. Medicare then pays you 80% of the approved amount, less any unmet portion of the Part B deductible. In Minnesota, the Minnesota Care Law requires doctors to bill at Medicare's allowed charge. This law applies only for Minnesota residents who receive services from a doctor in Minnesota. - What is coinsurance? (04/01/04)
Coinsurance represents the difference between the Medicare approved amount and the Medicare payment. The patient is responsible for paying the coinsurance amount. If a patient has supplemental insurance, it may help pay this amount. It is 20% of the approved amount. - What is the difference between Medicare and Medicaid?
(04/01/04)
Medicare is a federal health insurance program for the elderly and disabled. Medicaid is a medical assistance program jointly financed by the state and federal governments for eligible low-income individuals. Medicaid does restrict eligibility based on income and assets. - How do I sign up for Medicare? (04/01/04)
If you are already receiving Social Security payments when you turn 65, you will automatically receive your Medicare card in the mail. The card will show your entitlement to Parts A & B and the effective dates of each. If you do not want Part B, follow the instructions that come with the card to cancel it.
If you are not receiving Social Security payments, you may have to apply for Medicare. Please check with the Social Security Administration office at (800) 772-1213 for more information. If you must file for Medicare benefits, you should do so three months before you turn 65. - How do I replace a lost or stolen Medicare card? (04/01/04)
To replace your card, you should contact the Social Security Administration. You may either visit them at the field office nearest your home or contact them through their toll-free number, (800) 772-1213. To find the Social Security Administration office closest to you, check the government pages of your telephone directory under United States, Social Security Administration. - How do I update my permanent address with Medicare Part B? (01/27/05)
Contact your Social Security Administration office at 1-800-772-1213. The SSA maintains and updates your Medicare Part B enrollment file, including your address. Once you have notified the office of the change, you may also want to notify Medicare Part B, especially if you are waiting for claims to be resolved. You can contact Medicare Part B at 1-800-MEDICARE (1-800-633-4227) - When can I return to fee-for-service Medicare after
being in a managed care plan? (04/01/04)
You can leave a managed care plan at any time to join another plan or to return to fee-for-service Medicare. - May I receive services from a provider/supplier that are not
covered by Medicare? (04/01/04)
Yes. A physician may provide services to a beneficiary even if it is not a Medicare benefit. A provider does not have to bill Medicare for any service that is not a benefit. You may, however, ask if your provider will submit a claim to Medicare for denial before billing you for the service. - Who do I contact if I have a complaint about quality
of care? (04/01/04)
Every state has a Quality Improvement Organization to address quality of care issues. Please contact the Quality Improvement Organization in your area. - Will Medicare pay for a routine yearly physical examination?
(04/01/04)
No. Medicare medical insurance does not cover the cost of routine physical exams by your physician. Medicare will also not cover any test related to the routine physical. You are responsible for the payment of these services. - How long does a provider have to submit a claim? (12/31/07)
Claims must be filed with Medicare by the end of the calendar year following the year in which the services were provided.
Service Dates Date by which Claim Must Be Filed 10-01-05 through
09-30-0612-31-07 10-01-06 through
09-30-0712-31-08 10-01-07 through
09-30-0812-31-09 If providers submit an assigned claim 12 months or more after the date of service, their reimbursement may be reduced by 10%. Failure to submit a claim on time may result in the claim being denied. The patient is only responsible for 20% of the amount that Medicare would have approved for the service.
- What is a limiting charge? (04/01/04)
When a doctor does not accept assignment, there are limits on the amount he or she can charge you for most services. The doctor is allowed to charge 115 % of what Medicare approves. This is referred to as the limiting charge. - How often will Medicare Part B pay for a mammogram?
(04/01/04)
Medicare Part B covers mammogram screening on a yearly basis for female beneficiaries age 40 or older. One screening mammography is covered for female Medicare beneficiaries between their 35th and 40th birthdays. Medicare does not cover mammogram screening for women younger than age 35. Mammogram screening is intended to detect breast cancer early, before the patient shows signs or symptoms of the disease. It's important that you talk with your health care provider to determine whether you're a candidate for screening mammography or diagnostic mammography. A diagnostic mammogram is done when there is a sign or symptom of breast disease. The Part B deductible is waived for screening mammograms. - Can my provider/supplier bill me for filing claims? (01/27/05)
Congress passed legislation that requires providers to file your Medicare Part B claims for you. They cannot, under this law, charge you for filing claims or give you completed claims to mail. If your provider doesn't file your claims, please call 1-800-MEDICARE. - Will Medicare Part B cover services when I am out of
the country? (04/01/04)
In general, care provided outside of the United States (and its territories) is not covered by the Medicare Part B program. This limitation includes care provided by cruise-ship physicians. Two exceptions exist involving Canada and Mexico. - Is a physician or practitioner allowed to withdraw from
the Medicare Program? (04/01/04)
Answer: Yes, but only if certain criteria are met.
Under Section 1802 of the Social Security Act, as amended by the Balanced Budget Amendment of 1997, only certain physicians and practitioners were allowed to enter into private contracts with Medicare beneficiaries and "OPT OUT" of Medicare. With the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, §1802(b)(5)(B) of the Social Security Act, dentists, podiatrists, and optometrists were added to the definition/list of physicians who may opt out of Medicare. This went into effect on December 8, 2003. You may see a list of physicians and practitioners who have OPTED OUT of the Medicare program in Wisconsin, Illinois, Michigan, and Minnesota by clicking here.
"Practitioners" permitted to opt out are physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical social workers and clinical psychologists. Physical therapists in independent practice and occupational therapists in independent practice are not allowed to "opt out" under the law's current definitions.
If a Medicare beneficiary sees one of these physicians or practitioners, the beneficiary will be asked to sign a contract, unless the visit is an emergency or urgent situation. The contract makes the patient SOLELY responsible for payment. A beneficiary may not be asked to sign a private contract if facing an emergency or urgent health situation. - Why is the eye refraction portion of my visit to the
optometrist not covered? (04/01/04)
Medicare pays for things that are medically necessary. Determination of the refractive state is a measurement. - Is it true that if you delay enrolling in Medicare that you may have to pay a penalty when enrolling at a later date? (04/01/04)
Yes it is true. Late enrollment into Medicare will increase your premium by 10% for each year you could've been enrolled but were not.
However, if you did not take Medicare Part B when you were first eligible because you or your spouse were working and you were covered by a group health plan or union, you can enroll at a later date without having to pay a penalty. You can sign up for Medicare Part B during a Special Enrollment Period. You can sign up:- Anytime you are still covered by the employer or union group health plan through your or your spouse's current or active employment, or
- During the 8 months following the month the employer or union group health plan coverage ends, or when the employment ends (whichever is first).
Contact Social Security Administration for more information at 1-800-772-1213 or visit www.ssa.gov. - I receive Social Security disability benefits. When should my Medicare benefits start? (04/01/04)
You will be automatically enrolled in Medicare after you have received your disability benefits for two years. If you have Lou Gehrig's disease (ALS), your Medicare benefits begin the first month you receive disability benefits from Social Security. For more information contact Social Security Administration at 1-800-772-1213 or visit their website at www.ssa.gov. - Does Medicare pay for flu shots? (04/01/04)
Yes, Medicare pays for a flu shot once every flu season. It is recommended that you received the flu shot every year in the early fall. You can get a flu shot at a doctor's office, hospitals, medical clinics or your local health department. Medicare pays 100% of the allowed amount for the flu shot. Be sure talk to your doctor about receiving a flu shot. - Does Medicare cover dental work? (04/01/04)
Medicare does not cover routine dental care or procedures. This includes cleanings, fillings, teeth extractions or dentures. - Why does Medicare send out a Medicare Summary Notice? (04/01/04)
Whenever Medicare processes a claim, we send you a statement or Medicare Summary Notice (MSN), to inform you of the claims we process. Your MSN contains important information. It tells you -- The service provided
- Who performed it
- Medicare's determination
- Your financial responsibility, and
- How to file an appeal
Check your MSN to make sure that you received the services that Medicare paid for and report any instances of fraud to the number located in the Customer Service Information box. - What is an Advance Beneficiary Notice and how can it help me? (04/01/04)
An Advance Beneficiary Notice, or ABN, is a written notice that tells you why Medicare probably (or certainly) will not pay for a service or supply and that you will be responsible for the charges. It protects you from unexpected bills. If you are presented with an ABN, you will need to make a decision whether or not to receive the service or supply. If Medicare does not pay for it, then you are responsible for the charges. You should be provided a copy of the ABN for your records.
Read the ABN carefully. It should include -- A description of the service or supply
- The reason why they believe Medicare will no pay
- The date (must be on or before the date you receive the service or supply)
For services that Medicare never covers, such as a routine exam, an ABN is not necessary. - Does Medicare cover colonoscopies? (04/01/04)
Yes, once every 24 months if you are at high risk for colorectal cancer. If you are not at high rish for colorectal cancer, it is covered once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy. - What is the deductible for 2008? (12/31/07)
$135.00 - Can I pay my deductible directly to Medicare? (12/31/07)
No. We apply your deductible to services rendered at the first of the year. You are then liable to pay your provider for those services until your deductible has been met. - Who decides which preventative visits are covered by Medicare? (04/01/04)
Legislature, the Department of Health and Human Services (DHHS), and the Centers for Medicare & Medicaid Services (CMS). - If I miss the 7-month enrollment period, when is my next chance to enroll? Also, is there a higher premium if you enroll late? (04/01/04)
There is an open enrollment period from 1/1 - 3/31 of every year. You will be eligible for Part B as of 7/1. Usually there is a 10% increase for each year you were not enrolled. There can be exceptions depending on the circumstances. The Social Security Administration (SSA) determines this. You can contact the SSA for more information at: www.ssa.gov. - When I enroll in Medicare Part B, do I lock into the premium for that year or do I have to pay whatever the premium is for that year? (04/01/04)
You do not lock in to a premium fee. You have to pay the premium price for each specific year. - I am no longer working (retired). Who is responsible to update my insurance record at Medicare? (04/01/04)
It is the beneficiary's responsibility to contact the Coordination of Benefits (COB) contractor in New York at 1-800-999-1118 to have records updated. Medicare can be contacted after the COB contractor has updated the record to correct any claims processed incorrectly. - What does "Medically Necessary" mean? (06/18/04)
"Medically Necessary" is defined as a service, treatment, procedure, equipment, drug, device, or supply provided by a hospital, physician, or other health care provider that is required to identify or treat a beneficiary's illness or injury, and:- Is proper and needed for the diagnosis, or treatment of your medical condition;
- Is provided for the diagnosis, direct care, and treatment of your medical condition;
- Meets the standards of good medical practice in the local area; and
- Is not mainly for the convenience of you or your doctor.
- Some treatments may be limited by Medicare guidelines.
- What is the "Welcome to Medicare Physical" and can I have one? I am signed up for Medicare Part A and B. (04/28/05)
The Medicare Modernization Act (MMA) added payment for the "Welcome to Medicare Physical Exam." If you have Medicare Part B on or after January 1, 2005, Medicare will cover a one-time preventive physical exam within the first six months that you have Part B. The "Welcome to Medicare Physical Exam" includes a measure of your height, weight, and blood pressure, an EKG, training, and guidance.
Page Last Updated: Thursday, 17-Jul-2008 10:11:18 CDT
