MEDICARE CORNER
Let’s Review How Medicare Works for You!
MEDICARE PROVIDERS:
FULLY PARTICIPATING MEDICARE PROVIDER
Provider accepts Medicare assignment in full.
Beneficiary may be responsible for deductible
and coinsurance. The following Providers must
always accept assignment:
• Most Non-Physicians Practitioners
• Psychologist
• Social Workers
• Certain service Providers such as Ambulance,
Lab tests and Beneficiaries with Medicaid
NON-PARTICIPATING MEDICARE PROVIDER
Provider accepts Medicare, but does not
accept Medicare assigned amount in full.
Can charge Beneficiary up to %15 above the
Medicare allowed amount.
OPT-OUT PROVIDER
Provider does not accept Medicare. If Client
is a Medicare Beneficiary, the Opt-Out Provider
will have the Client sign a contract for payment.
Client will be responsible to pay the Provider’s
“going rate.” Exception: If an Opt-Out Provider
renders services during an emergency, such as
in an emergency room, the Beneficiary may be
exempt from paying the Provider’s “going rate.”
VA AND TRICARE
• Veterans may delay enrolling in a Medicare
Part D Plan without penalty but cannot delay
enrolling in Part B without a penalty
• VA and Tricare provide creditable Part D
Coverage
• VA does not supplement Medicare and
Medicare does not help with VA cost-sharing
• VA coverage counts toward a pre-existing
condition waiting period when enrolling in
a Medigap (Supplemental) Plan
• Tricare acts as a supplement to Medicare
• Tricare Military Retirees must enroll in Part
A and B
ADVANCE BENEFICIARY NOTICE
The Advance Beneficiary Notice (ABN) is
given to a Beneficiary when services may not
be covered. The ABN should be submitted to
Medicare. Medicare might pay even if the ABN
was signed. If Medicare does not pay for the
claim, the Beneficiary is responsible to pay the
Provider’s fee.
If Services are excluded services, meaning
these are services that Medicare never pays, an
ABN is not required. The Beneficiary is always
responsible to pay. Such services include, acupuncture,
dentures, etc.
PHYSICAL THERAPY
In 2018, Congress eliminated how much
Medicare will pay for Physical Therapy.
Provider must confirm services are Medically
Necessary when the therapy reaches the $2,010
threshold. At the $3,000 threshold, a Medicare
Contractor will review the claim for Medical
Necessity. If Therapist is not willing to provide
services beyond the $3,000 threshold,
the Therapist can offer Beneficiary an ABN
(see above).
PART B DRUG COVERAGE
Tetanus Vaccine, if given as an outpatient
for treatment of an injury. Immunosuppressive
drugs following an organ transplant, if Medicare
covered the transplant.
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October 2018 ¢ NORTH SHORE TOWERS COURIER 33
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