Medicare and Caregivers
Understanding Medicare Billing
To help the person you care for manage medical expenses, it is important to understand Medicare billing. Knowing about premiums, deductibles, co-insurance, co-payments, and which insurance pays first or second when the person is covered by more than one health insurance plan can help you and the person you care for better handle Medicare billing.
A premium is the periodic payment a person makes for health or prescription drug coverage. Most people don't have to pay a monthly premium for Medicare Part A (hospital insurance), but people who choose Part B (medical insurance) must pay a monthly premium. This monthly premium is paid in addition to any deductibles, co-insurance, or co-payments.
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The deductible is the amount that a person must pay for health care or prescriptions before Original Medicare, the person's prescription drug plan, or other insurance begins to pay. For example, in Original Medicare, the person with Medicare pays a new deductible for each benefit period for Part A and each year for Part B. These amounts can change every year.
Co-insurance is the amount a person may be required to pay for services after he or she pays any plan deductibles. In Original Medicare, this is a percentage (about 20%) of the Medicare-approved amount. The person will have to pay this amount after he or she pays the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the co-insurance will vary depending on how much the person has spent.
In some Medicare health and prescription drug plans, a co-payment is the amount the person will pay for each medical service, like a doctor's visit or prescription. A co-payment is usually a set amount. For example, this could be $10 or $20 for a doctor's visit or prescription. Co-payments are also used for some hospital outpatient services in Original Medicare.
Coordination of Benefits
When a person with Medicare is covered by more than one health insurance plan, there are rules about whether Medicare or the other insurer pays health care bills first. This is called "coordination of benefits." Sometimes, the other health insurance pays the person's health care bills first, and the person's Original Medicare Plan or Medicare Advantage (MA) Plan pays second.
Other insurance that may pay first includes an employer's or union's group health plan coverage, no-fault insurance, liability insurance, black lung benefits, or workers' compensation. If the person has other insurance, it is important to tell his or her doctor, hospital, and pharmacy so that the bills get paid correctly.
Medicare Summary Notice
If the person you care for is in Original Medicare, he or she will get a Medicare Summary Notice (MSN) in the mail every three months if he or she had a Medicare covered service during that period. The notice lists the services received by the person you care for and the amount he or she may be billed by a hospital, doctor, or other provider. These notices are sent by companies that handle bills for Medicare.
For more information about the Medicare Summary Notice, including a sample MSN and information on how to read it, visit http://www.medicare.gov and select "Medicare Billing." Or call 1-800-Medicare (1-800-633-4227) and say "Billing." TTY users should call 1-877-486-2048.
Notices and bills for Medicare Advantage Plans and Medigap policies will look different than the MSN for people in Original Medicare. If you have a question about a Medicare Advantage Plan or Medigap policy, you will need to call the benefits coordinator at the company or health plan that offers the plan. To locate telephone numbers, you can look at the notice or bill from the plan. Or, you can call 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.
The Right to Appeal
A person with Medicare has the right to appeal any decision about his or her Medicare services. This is true whether the person is in Original Medicare, a Medicare managed care plan, or a Medicare prescription drug plan. If the person doesn't agree with the amount that Medicare paid, or thinks that a service has been unreasonably denied, the person can appeal.
Information on how to file an appeal is on the Medicare Summary Notice (MSN), in the health plan materials, or in the drug plan materials. If the person you care for decides to file an appeal, ask the doctor or provider for any information that may help the case. You can also call the State Health Insurance Assistance Program (SHIP) for help filing an appeal. If the person you care for wants someone to file an appeal on his or her behalf, the person will need to complete an "Appointment of Representative" form.
For more information about appeals, visit http://www.medicare.gov to view or print a copy of "Your Medicare Rights and Protections." (Under "Search Tools," select "Find a Medicare Publication.") You can also call 1-800-Medicare (1-800-633-4227) to find out if a free copy can be mailed to you. TTY users should call 1-877-486-2048.