General Medicare Frequently Asked Questions (FAQs)

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  1. What is the Medicare Summary Notice (MSN)? (Reviewed 10/23/14)
  2. How long should I wait before contacting Medicare to check on the status of a claim? (Reviewed 10/23/140)
  3. What is a "participating provider"? (Reviewed 10/23/14)
  4. What is a "non-participating provider"? (Reviewed 10/23/14)
  5. What is coinsurance? (Reviewed 10/23/14)
  6. What is the difference between Medicare and Medicaid? (Reviewed 10/23/14)
  7. How do I sign up for Medicare? (Reviewed 10/23/14)
  8. Is it true that if you delay enrolling in Medicare, you may have to pay a penalty when enrolling at a later date?
    (Reviewed 10/23/14)
  9. I receive Social Security disability benefits. When will my Medicare benefits start? (Reviewed 10/23/14)
  10. How do I replace a lost or stolen Medicare card? (Reviewed 10/23/14)
  11. How do I update my permanent address with Medicare Part B? (Reviewed 10/23/14)
  12. When can I leave my managed care plan and return to Original Medicare? (Reviewed 10/23/14)
  13. May I receive services from a provider/supplier that are not covered by Medicare? (Reviewed 10/23/14)
  14. Whom should I contact if I have a complaint about quality of care? (Reviewed 10/23/14)
  15. Will Medicare pay for a routine yearly physical examination? (Reviewed 10/23/14)
  16. How long does a provider have to submit a claim? (Reviewed 10/23/14)
  17. How often will Medicare Part B pay for a mammogram? (Reviewed 10/23/14)
  18. Can my provider/supplier bill me for filing claims? (Reviewed 10/23/14)
  19. Will Medicare Part B cover services when I am out of the country? (Reviewed 10/23/14)
  20. Is a physician or practitioner allowed to withdraw from the Medicare Program? (Reviewed 10/23/14)
  21. Why is the eye refraction portion of my visit to the optometrist not covered? (Reviewed 10/23/14)
  22. Does Medicare pay for flu shots? (Reviewed 10/23/141)
  23. Does Medicare cover dental services? (Reviewed 10/23/14)
  24. What is an Advance Beneficiary Notice of Non-Coverage (ABN) and how can it help me? (Reviewed 10/23/14)
  25. Does Medicare cover colonoscopies? (Reviewed 10/23/14)
  26. Can I pay my deductible directly to Medicare? (Reviewed 10/23/14)
  27. Who decides which preventative visits are covered by Medicare? (Reviewed 10/23/14)
  28. If I miss the 7-month enrollment period, when is my next chance to enroll? Also, is there a higher premium if I enroll late? (Reviewed 10/23/14)
  29. I am no longer working (retired). Who is responsible to update my insurance record at Medicare? (Reviewed 10/23/14)
  30. What does "Medically Necessary" mean? (Reviewed 10/23/14)
  31. What is the "Welcome to Medicare Physical" and can I have one? I am signed up for Medicare Part A and B. (Reviewed 10/23/14)
  32. Will Medicare Part B reimburse my physician for administering a vaccine such as Zostavax (shingles), Pertussis, Tetanus, or Diphtheria? Will Medicare Part B reimburse my physician for the cost of the drug? (Reviewed 10/23/14)
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All FAQs are current as of the date noted next to the question.

  1. What is the Medicare Summary Notice (MSN)? (Reviewed 10/23/14)

    The MSN is a statement Medicare sends to people with Medicare that summarizes all of their inpatient and outpatient claims information processed by Medicare over a 90-day period. It is important that people with Medicare check their MSNs to make sure that they received the services that Medicare paid for and report any instances of fraud to 1-800-MEDICARE (1-800-633-4227).

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  3. How long should I wait before contacting Medicare to check on the status of a claim? (Reviewed 10/23/14)

    WPS Medicare processes most claims within 30 days of receipt; however, if we need to ask for additional information from you or your provider, it may take longer. To check the status of a claim at any time, please contact Contact Center Operations at 1-800-MEDICARE (1-800-633-4227). If you are not due a payment check from Medicare, your Medicare Summary Notices (MSNs) are mailed to you on a quarterly basis (every 90 days). If you do not receive your MSNs timely, please contact Contact Center Operations at 1-800-MEDICARE (1-800-633-4227).

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  5. What is a "participating provider"? (Reviewed 10/23/14)

    A participating provider is a health care provider that has 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, after your yearly deductible is met. The remaining amount, called coinsurance, is your responsibility. Some Medicare supplement insurance plans may help pay your coinsurance and deductible.

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  7. What is a "non-participating provider"? (Reviewed 10/23/14)

    A non-participating provider is a health care provider who does not agree to accept assignment on all Medicare claims. If a non-participating provider does not accept assignment on a claim, he or she may charge more than Medicare's approved amount, but not more than the limiting charge. The limiting charge is 115 % of the Medicare approved amount. A non-participating provider may also collect full payment directly from the patient at the time of service. When a provider does not accept assignment on a claim, Medicare sends its payment directly to the beneficiary, not to the provider.

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  9. What is coinsurance? (Reviewed 10/23/14)

    Coinsurance is the amount the patient is responsible for paying once their deductible has been met. This amount is equal to the difference between the Medicare approved amount and the Medicare payment, which is usually 20% of the approved amount. If a patient has supplemental insurance, it may help pay this amount.

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  11. What is the difference between Medicare and Medicaid? (Reviewed 10/23/14)

    Medicare is a Federal health insurance program for the elderly, disabled, and people with permanent kidney failure. Medicaid is a medical assistance program jointly financed by the State and Federal governments for eligible low-income individuals.

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  13. How do I sign up for Medicare? (Reviewed 10/23/14)

    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 Medicare Parts A and B and the effective dates of each.

    If you are not receiving Social Security payments, you may have to apply for Medicare. Please check with the Social Security Administration office at 1-800-772-1213 for more information. If you must file for Medicare benefits, you should do so three months before you turn 65.

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  15. Is it true that if you delay enrolling in Medicare, you may have to pay a penalty when enrolling at a later date? (Reviewed 10/23/14)

    Yes, it is true. Late enrollment into Medicare will increase your premium by 10% for each year you could have enrolled but did 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 if you 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 the Social Security Administration for more information at 1-800-772-1213 or visit http://www.ssa.gov(external link).

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  1. I receive Social Security disability benefits. When will my Medicare benefits start? (Reviewed 10/23/14)

    You will be automatically enrolled in Medicare after you have received your disability benefits for two years. In some cases, you may be eligible sooner. For more information, contact the Social Security Administration at 1-800-772-1213 or visit their website at http://www.ssa.gov(external link).

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  3. How do I replace a lost or stolen Medicare card? (Reviewed 10/23/14)

    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 by telephone at 1-800-772-1213. To find the Social Security Administration office closest to you, check the government pages of your telephone directory under United States, Social Security Administration. You can also locate the nearest field office on the Social Security Administration website.

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  5. How do I update my permanent address with Medicare Part B? (Reviewed 10/23/14)

    The Social Security Administration maintains and updates your Medicare enrollment file, including your address. To update your address, you may either visit the Social Security Administration field office nearest your home or contact the Social Security Administration by telephone at 1-800-772-1213.

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  7. When can I leave my managed care plan and return to Original Medicare, or vice versa? (Reviewed 10/23/14)

    During the Open Enrollment period (October 15 through December 7), anyone can join, switch, or drop a Medicare managed care plan. Your changes become effective on January 1.Between January 1 and February 14, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to join a Medicare Prescription Drug Plan to add drug coverage.

    For more information about disenrolling from your managed care plan, contact 1-800-MEDICARE (1-800-633-4227).

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  9. May I receive services from a provider/supplier that are not covered by Medicare? (Reviewed 10/23/14)

    Yes. A physician may provide services to a beneficiary that are not covered by Medicare, but the person with Medicare may be responsible for the full cost of the services. A provider does not have to bill Medicare for any service that is not covered. However, you may ask if your provider to submit a claim to Medicare for denial before billing you for the service.

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  11. Whom should I contact if I have a complaint about quality of care? (Reviewed 10/23/14)

    Every state has a Quality Improvement Organization (QIO) to address quality of care issues. You can contact 1-800-MEDICARE (1-800-633-4227) to find the contact information for your area's Quality Improvement Organization.

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  13. Will Medicare pay for a routine yearly physical examination? (Reviewed 10/23/14)

    No. However, Medicare does cover an annual wellness visit (AWV). An AWV is not a physical, but it does include a review of the beneficiary's basic health measurements (e.g., height, weight, blood pressure, etc.) and his or her medical history. The doctor also reviews the beneficiary's risk factors for certain other diseases and conditions, and develops a personalized plan for prevention services.

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  15. How long does a provider have to submit a claim? (Reviewed 10/23/14)

    In general, claims must be submitted to Medicare within one calendar year after the date of the service. For example, for a service provided on November 25, 2014, Medicare must receive the claim no later than November 24, 2015. In rare cases, Medicare can waive the time limit for filing a claim if the delay in filing was due to an error by Medicare, retroactive Medicare entitlement, or delayed disenrollment from a Medicare Advantage plan.

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  16. How often will Medicare Part B pay for a mammogram? (Reviewed 10/23/14)

    Women age 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between ages 35 and 39. Medicare does not cover screening mammograms for women younger than age 35. Medicare can also cover a diagnostic mammogram when there is a sign or symptom of breast disease. Medicare covers diagnostic mammograms for both women and men whenever they are medically necessary.

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  18. Can my provider/supplier bill me for filing claims? (Reviewed 10/23/14)

    No. Congress passed legislation that requires providers to file your Medicare claims for you. They cannot 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 (1-800-633-4227).

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  20. Will Medicare Part B cover services when I am out of the country? (Reviewed 10/23/14)

    In general, the Medicare program does not cover care provided outside of the United States or its territories. There are limited exceptions, including some cases when Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. More information on this subject is available in the "Medicare & You," handbook.

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  22. Is a physician or practitioner allowed to withdraw from the Medicare program? (Reviewed 10/23/14)

    Yes, in some cases providers may opt out of the Medicare program. If a beneficiary sees a provider who has opted out of Medicare, the beneficiary will be asked to sign a contract before receiving any services from the provider. The contract makes the beneficiary responsible for full payment of the provider's charges. By signing the contract, the beneficiary agrees not to submit a claim to Medicare. A beneficiary may not be asked to sign a private contract if facing an emergency or urgent health situation.

    You may see a list of physicians and practitioners who have opted out of the Medicare program on our website.

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  24. Why is the eye refraction portion of my visit to the optometrist not covered? (Reviewed 10/23/14)

    Most services having to do with prescribing glasses and contact lenses are excluded from coverage. Medicare does not cover refractions because a refraction is a routine service.

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  26. Does Medicare pay for flu shots? (Reviewed 10/23/14)

    Yes, Medicare pays for a flu shot once every flu season. Medicare pays 100% of the allowed amount for the flu shot.

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  28. Does Medicare cover dental services? (Reviewed 10/23/14)

    Medicare does not cover routine dental care or procedures. This includes cleanings, fillings, tooth extractions or dentures.

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  30. What is an Advance Beneficiary Notice of Non-Coverage (ABN) and how can it help me? (Reviewed 10/23/14)

    An ABN is a written notice that tells you why Medicare probably (or certainly) will not pay for an item or service, and it informs you that you will be responsible for the charges if Medicare does not pay. 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 item or service. Your health care provider must provide you a copy of the ABN for your records.

    Read the ABN carefully. It must include:

    • A description of the service or supply,
    • The reasons why the provider believes Medicare will not pay,
    • The date (The ABN must be given to you on or before the date you receive the service or supply.)

    For services that Medicare never covers, such as a routine exam, your doctor does not need to provide you an ABN.

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  1. Does Medicare cover colonoscopies? (Reviewed 10/23/14)

    Yes, Medicare covers a screening colonoscopy once every 24 months if you are at high risk for colorectal cancer. If you are not at high risk for colorectal cancer, Medicare covers a screening colonoscopy once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy. Medicare can cover a diagnostic colonoscopy whenever it is medically necessary.

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  3. Can I pay my deductible directly to Medicare? (Reviewed 10/23/14)

    No. Medicare notifies your providers of which claims have deductible applied. Your providers then collect your deductible from you or a supplemental insurer.

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  5. Who decides which preventative visits are covered by Medicare? (Reviewed 10/23/14)

    Coverage decisions are made by Congress, the Department of Health and Human Services (DHHS), and the Centers for Medicare & Medicaid Services (CMS).

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  7. If I miss the 7-month enrollment period, when is my next chance to enroll? Also, is there a higher premium if I enroll late? (Reviewed 10/23/14)

    There is an open enrollment period from January 1 - March 31 of every year. Usually there is a 10% increase in your premium for each year you were not enrolled after you were eligible. There can be exceptions depending on the circumstances. To determine if you must pay a higher premium, please contact the Social Security Administration (SSA) at 1-800-772-1213 or visit your local SSA office. You can also find information on the SSA website(external link).

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  9. I recently retired from my job, so I no longer have insurance through my employer. Who is responsible for updating my insurance record at Medicare? (Reviewed 10/23/14)

    It is the beneficiary's responsibility to contact the Benefits Coordination & Recovery Center (BCRC) 1-855-798-2627 to have his or her records updated.

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  11. What does "Medically Necessary" mean? (Reviewed 10/23/14)

    "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.

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  1. What is the "Welcome to Medicare" preventive visit and can I have one? I am signed up for Medicare Parts A and B. (Reviewed 10/23/14)

    The Medicare Modernization Act (MMA) added coverage of the Initial Preventive Physical Examination, which is also known as the "Welcome to Medicare" visit. Medicare will cover a one-time preventive physical exam within the first 12 months that you have Part B. The "Welcome to Medicare" visit includes a measurement of your height, weight, and blood pressure, as well as training and guidance. You can find more information regarding the "Welcome to Medicare" visit on the Medicare.gov websiteExternal Link.

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  3. Will Medicare Part B reimburse my physician for administering a vaccine such as Zostavax (shingles), Pertussis, Tetanus, or Diphtheria? Will Medicare Part B reimburse my physician for the cost of the drug? (Reviewed 10/23/14)

    Medicare does not cover most vaccinations. The exceptions are the flu and pneumonia vaccines, which can be covered for all people with Medicare, and the hepatitis B vaccine, which can be covered for individuals at high risk for contracting the disease. Medicare may also cover certain vaccines if they are medically necessary. For example, Medicare Part B could reimburse a tetanus shot if the patient has sustained a wound and has not received a booster in some time.

    Some vaccines may be covered under a Medicare Part D Prescription Drug Plan. Please contact your Prescription Drug Plan directly or contact 1-800-MEDICARE for more information.

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Page Last Updated: Thursday, 30-Oct-2014 14:40:14 CDT