The Health Care Financing Administration, the Social Security Administration and Medicare.
- Am I still responsible for the 20% coinsurance amount if my doctor submits the claim too late and it’s denied for late filing?
- What can I do if the Original Medicare plan (Part A Hospital Insurance or Part B Medical Insurance) says it won’t cover an item/service that I think should be covered?
- Why is Social Security still taking money out each month towards Medicare Part B when I have joined a Medicare Advantage plan?
Q: Am I still responsible for the 20% coinsurance amount if my doctor submits the claim too late and it’s denied for late filing?
- A:You have the right to talk with health care providers in private and to have your personal health care information kept private as protected under federal and state laws.
Patient privacy rules have changed, and you have more access to your own medical records and more control over how your personal health information is used by your health care provider or your health plan. This rule became fully effective on April 14, 2003.
If you have any questions about this privacy rule, look at the National Statndards to Protect the Privacy of Personal Health Information, on the web.
If you are in a Medicare-managed care plan or a Medicare Private Fee-for-Service plan, you also have the right to timely access to your medical records.
Q: Do you automatically get Medicare if you are getting Social Security disability benefits?
- A:You will automatically be enrolled in Medicare after you get Social Security disability benefits for two years. This starts 24 months from the month you were entitled to receive Social Security disability benefits. In some cases, this could be earlier than the month when you received your first check. You can get more information from the Social Security Administration at 1-800-772-1213 or on their website.
Q: Does Medicare cover me when I travel outside of the United States?
- A:Providers must submit claims to Medicare on their patient’s behalf. Although providers have between 15-27 months to submit a claim for reimbursement based on the date of service, sometimes a claim is not submitted timely and not considered for payment by Medicare. However, you are still responsible for the 20% coinsurance amount based on what Medicare would have allowed for the service had it not been submitted late. Your Medicare Summary Notice will inform you of the amount you are responsible to pay your provider.
Q: How can I protect myself from Medicare fraud?
- A:Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment. Keep in mind that the attempt itself is fraud, regardless of whether it’s successful.
Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person’s intent. Both have the same impact: they steal valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.
Q: How is the privacy of my medical records protected?
- A:Assignment is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies (like wheelchairs, oxygen, braces, and ostomy supplies). Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Part B services and supplies. You pay the coinsurance and deductible amounts. In some cases (such as if you have both Medicare and Medicaid), your health care providers and suppliers must accept assignment. If assignment is not accepted, charges are often higher. This means you may pay more. In addition, you may have to pay the entire charge at the time of service. Medicare will then send you its share of the charge. There is a limit on the amount your doctors and providers can bill you. The highest amount of money you can be charged for a covered service by doctors and other health care providers who don’t accept assignment is called the limiting charge. The limit is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.
Q: I’ll be 65 years old soon. When should I sign up for Medicare?
- A:Generally, you should file for Medicare benefits three months before turning age 65. Remember, Medicare benefits can begin no earlier than age 65. If you are already receiving Social Security, you will automatically be enrolled in Medicare Parts A and B without an additional application. However, because you must pay a premium for Part B coverage, you have the option of turning it down. You will receive a Medicare card about two months before turning age 65.
Q: What are the differences between Medicare Parts A, B, C and D?
- A:There are four parts to Medicare: Medicare Part A, Hospital Insurance; Medicare Part B, Medical Insurance; Medicare Part C (Medicare Advantage), which was formerly known as “Medicare + Choice” and the new Medicare Part D, prescription drug coverage. Generally, people who are over age 65 and getting Social Security automatically qualify for Medicare Parts A and B. So do people who have been getting disability benefits for two years, people who have amyotrophic lateral sclerosis (Lou Gehrig’s disease) and receive disability benefits, and people who have permanent kidney failure and receive maintenance dialysis or a kidney transplant.
Part A is paid for by a portion of Social Security tax. It helps pay for inpatient hospital care, skilled nursing care, hospice care and other services.
Part B is paid for by the monthly premiums of people enrolled and by general funds from the U.S. Treasury. It helps pay for doctors’ fees, outpatient hospital visits, and other medical services and supplies that are not covered by Part A.
Part C (Medicare Advantage) plans allow you to choose to receive all of your health care services through a provider organization. These plans may help lower your costs of receiving medical services, or you may get extra benefits for an additional monthly fee. You must have both Parts A and B to enroll in Part C.
Part D (prescription drug coverage) is voluntary and the costs are paid for by the monthly premiums of enrollees and Medicare. Unlike Part B in which you are automatically enrolled and must opt out if you do not want it, with Part D you have to opt in by filling out a form and enrolling in an approved plan.
Q: What are the requirements to receive Medicare hospital insurance?
- A:Most people 65 or older are eligible for Medicare hospital insurance (Part A) based on their own- or their spouse’s? employment. You are eligible at 65 if you:
- Receive Social Security or railroad retirement benefits
- Aren’t getting Social Security or railroad retirement benefits, but you have worked long enough to be eligible for them
- Would be entitled to Social Security benefits based on your spouse’s (or divorced spouse’s) work record, and that spouse is at least 62 (your spouse doesn’t have to apply for benefits in order for you to be eligible based on your spouse’s work); or
- Worked long enough in a federal, state, or local government job to be insured for Medicare
If You Are Under 65
Before age 65, you are eligible for Medicare hospital insurance if you:
- Have been a Social Security disability beneficiary for 24 months; or
- Have worked long enough in a federal, state, or local government job and you meet the requirements of the Social Security disability program
- If you receive a disability annuity from the Railroad Retirement Board, you will be eligible for hospital insurance after a waiting period. (Contact your railroad retirement office for details.)
Q: What are the requirements to receive Medicare Medical Insurance (also known as Part B)?
- A:Almost anyone who is 65 or older or who is under 65 but eligible for hospital insurance can enroll for Medicare medical insurance by paying a monthly premium. You don’t need any Social Security or government work credits for this part of Medicare.
Aliens who are 65 or older and aren’t eligible for hospital insurance must be lawfully admitted permanent residents and must live in the United States for five years before they can enroll for medical insurance.
Q: What can I do if the Original Medicare plan (Part A Hospital Insurance or Part B Medical Insurance) says it won’t cover an item/service that I think should be covered?
- A:Congress sets the prices Medicare pays for many items. These prices often do not take into account rebates that may be available from retail establishments. For example, Medicare pays a fixed amount for the glucometer that a diabetic uses to test his blood sugar. Many of these items currently have rebates that make them less expensive. Medicare cannot take into account such discounts.
Q: What is “assignment” in the Original Medicare Plan and why is it important?
- A:Medicare Advantage plans provide care under contract to Medicare. You must continue to pay the monthly Medicare Part B premium when you join a Medicare Advantage plan. You may also have to pay an additional monthly premium to the plan. For the plan premium, the plan may provide benefits like coordination of care or reduce out-of-pocket expenses. If you join a Medicare Advantage plan you are still in the Medicare program and are still entitled to get all your regular Medicare-covered services and have Medicare rights and protections.
Q: What is the difference between Medicare and Medicaid?
- A:Medicare is an insurance program. Medical bills are paid from trust funds that those who are covered have paid into. It primarily serves people over 65 and younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government.
Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments according to federal guidelines
Q: What is the difference between Medicare fraud and abuse?
- A:The Original Medicare Plan generally doesn’t cover health care while you are traveling outside the United States. Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are considered part of the United States.
There are some exceptions. In rare cases, Medicare can pay for inpatient hospital services that you get in Canada or Mexico. Medicare can pay only if:
- You live in the U.S. near a foreign hospital, and you need emergency or non-emergency medical treatment. If a foreign hospital is closer or easier to get to from your home than the nearest U.S. hospital that can treat your condition, Medicare may pay for the services.
- You’re in the U.S. when you have a medical emergency. If a foreign hospital is closer or easier to get to than the nearest U.S. hospital that can treat your emergency, Medicare may pay for the services.
- You’re crossing through Canada without delay between Alaska and another state, and you have a medical emergency. If a Canadian hospital is closer or easier to get to than the nearest U.S. hospital that can treat your emergency, Medicare may pay for the services.
Normal or other Medicare coverage criteria also applies to the services you get in foreign settings.
Some Medicare Advantage plans may provide worldwide coverage benefits for health care needs when you travel outside the United States. You should check with your Medicare Advantage plan prior to traveling outside of the United States regarding worldwide coverage benefits.
Medigap policies C, D, E, F, G, H, I, and J provide Foreign Travel Emergency health care coverage when you travel outside the United States.
Q: Why does Medicare pay so much for items that I can get more cheaply?
- A:Medicare is also reminding people with Medicare to keep their personal information safe. Don’t give your information to anyone who comes to your home (or calls you) uninvited, selling Medicare-related products. They can only give you information about a plan, and can’t ask you for your personal information or enroll you in a plan.
Only give personal information when you have made the contact. For example, you call or visit the websites of plans that are approved by Medicare; call or visit people in the community who work with Medicare, like your State Health Insurance Assistance Program or the Social Security Administration; or call 1-800-MEDICARE or visit www.medicare.gov on the web. People who are really working with Medicare won’t try to enroll you into a drug plan over the telephone unless you call them, or unless you are already in a Medicare Advantage Plan or other Medicare Health Plan, and they call to ask if you would like to add prescription drug coverage to the coverage you already have.
Call 1-800-MEDICARE if you aren’t sure if a plan is approved by Medicare. Plans are allowed to mail information and to call you. They aren’t allowed to sell plans door-to-door.
If you think someone is misusing your personal information, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048
- The Fraud Hotline of the HHS Office of the Inspector General at 1-800-447-8477. TTY users should call 1-800-377-4950
- The Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 to make a report (TTY users should call 1-866-653-4261)
Q: Why is Social Security still taking money out each month towards Medicare Part B when I have joined a Medicare Advantage plan?
- A:When you get Medicare prescription drug coverage, you pay part of the costs and Medicare pays part of the costs. You pay a premium each month to join the drug plan. If you have Medicare Part B, you also pay your monthly Part B premium. If you belong to a Medicare Advantage Plan or Medicare Cost Plan, the monthly premium you pay to the plan may increase if you add prescription drug coverage.
Your costs will vary depending on which plan you choose. Your plan must, at a minimum, provide a standard level of coverage as shown below. Some plans offer more coverage and/or vary the standard level of coverage by charging copayments based on drug tiers or lowering the deductible in exchange for higher out-pocket-costs later on.
Standard Coverage (the minimum coverage drug plans must provide)
Effective January 1, 2008, for covered drugs you will pay:
- A monthly premium (varies depending on the plan you choose)
- The first $275 per year for your prescriptions. This is called your deductible.
After you pay the $275 yearly deductible, here’s how the costs work:
- You pay 25% of your yearly drug costs from $275 to $2,510, and your plan pays the other 75% of these costs, then
- You pay 100% of your next $3,216.25 in drug costs, then
- You pay a coinsurance amount (like 5% of the drug cost) or a copayment (like $2.25 or $5.60 for each prescription) for the rest of the calendar year after you have spent $4,050 out-of-pocket. Your plan pays the rest.