Medicare ExpensesSubmitted by QSSA - Better Financial Solutions for Life on December 6th, 2017
Covered Medicare Charges
What is Assignment?
December 7th 2018 is the end of the Medicare’s Annual Open Enrollment season for 2019 where you can make changes to your current Medicare insurance plan. But, what charges are covered by Medicare and by your specific plan? What does Assignment mean?
Side Note: If you belong to a Medicare Advantage plan your MUST be enrolled in Medicare Parts A and B however; when you use a provider you only show your insurance card (not your Medicare Card). Showing both cards will only confuse the billing of covered services.
If you are enrolled in a Medicare Supplement plan then you should show both cards (Medicare Card and insurance card). A supplement plan will not cover expenses that are not covered by Medicare. For example, Medicare covers 80% of approved charges. Most supplement plans will cover the additional 20%.
With few exceptions, the general rule is - if Medicare doesn't’t cover the expense then you’re insurance will not cover the expense either! Non-covered charges may be your responsibility. If you’re enrolled in a Medicare Advantage plan, some plans may pick up additional costs not covered by Medicare (i.e. glasses, hearing aids, gym memberships, etc.) but the tradeoff may be that you have to use a service provider that belongs to the network in order to be a covered expense. For an HMO (health maintenance organization) you have to use a network service provider that is in the plan. If you’re enrolled in another type of Medicare Advantage plan (PPO, PFFS, MSA) you may be permitted to use services outside the network but generally, you will pay more for the services and again, the service provider has to accept Medicare.
Medicare Supplement Plans are designed to cover the gaps in coverage for approved expenses. There are NO networks and you can obtain services from any doctor, provider or supplier in the USA that accepts Medicare or that one that accepts Medicare assignment.
What are the rules if my provider does not accept assignment?
- Participating doctors, provider, and supplier (PAR) have signed an agreement to accept assignment for all Medicare-covered services.
- Your out-of-pocket cost should be less
- You are only charged and are only responsible for the Medicare deductible and/or coinsurance amounts
- Provider may not ask you for payment until Medicare has paid their share
- Provider submits claims directly to Medicare and can’t charge you for submitting the claim
- Non-participating providers (Non-PAR)
- Have No signed agreement to accept assignment for Medicare-covered services “non-participating”
- May require payment at the time of service
- Supposed to submit your claim to Medicare for any Medicare-covered services that they provide.
- Can’t charge you for submitting a claim
- Call 1-800-MEDICARE if they don’t submit the claim when asked
- Can charge you more than the Medicare-approved amounts. Usually, these charges are limited to 115% of the Medicare charge. Medicare reduces these charges by 5% by so the actual excess charges are really about additional 9%
- Private contracting doctors – Medicare WILL NOT pay for these services
- Has chosen to opt-out of Medicare
- Must enter into a private contract with you that meet specific requirements and you must be signed the agreement to be covered
- Can charge their own rates and are not bound by the Medicare fee schedule
- You will not be reimbursed by Medicare or your Medicare Supplement policy
- May not choose to cover some patients under Medicare. It’s all or nothing!
Under all circumstances’ you are always covered for an Emergency
Please contact me with any questions or for more information: