WHO QUALIFIES FOR MEDICARE BENEFITS?
• Individuals 65 years of age or older
• Individuals under 65 with permanent kidney failure (beginning three months after dialysis begins), or
• Individuals under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits)
THE DIFFERENT BENEFITS OF TRADITIONAL MEDICARE
Medicare Part A benefits cover hospital stays, home health care and hospice services.
Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment.
While oftentimes you do not have to pay a monthly fee to have Part A benefits (you only have to pay money when you use the services), the Part B program requires a monthly premium to stay enrolled (even if you do not use the services). In 2011 that premium will range between $115.40- $369.10 per month depending on your income. Typically, this amount will be taken from your Social Security check.
Medicare Part D offers optional program benefits that cover prescription drugs.
For more information about your benefits or making coverage decisions, you can visit the official website for Medicare benefits at www.medicare.gov.
WHAT CAN YOU EXPECT TO PAY?
Every year, in addition to your monthly premium, you will have to pay the first $162 of covered expenses out of pocket for Part B services, and then 20 percent of all approved charges if the provider agrees to accept Medicare payments.
Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. They must attempt to collect the coinsurance and deductible if those charges are not covered by another insurance plan.
If you have a supplemental insurance policy, that plan may pick up this portion of your responsibility after your supplemental plan’s deductible has been satisfied.
If your medical equipment provider does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if the charges are approved.
OTHER POSSIBLE COSTS:
Medicare will pay only for items that meet your basic needs. Often times you will find that your provider offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your provider should give you the option to allow you to privately pay a little extra money to get the product that you really want.
To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows you to upgrade to a piece of equipment that you like better than the other standard option you may otherwise qualify for. This form is known as the Advance Beneficiary Notice or ABN.
The ABN your provider completes for you must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket.
PURPOSE OF ABN
The Advance Beneficiary Notice of Non Coverage also will be used to notify you ahead of time that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should be detailed enough that you understand why Medicare will probably not pay for the item you are requesting.
The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses.
UNDERSTANDING ASSIGNMENT (a claim-by-claim contract)
When a provider accepts assignment, they are agreeing to accept Medicare’s approved amount as payment in full.
You will be responsible for 20 percent of that approved amount. This is called your coinsurance.
You also will be responsible for the annual deductible, which is $162.00 for 2011.
If a provider does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.)
MANDATORY SUBMISSION OF CLAIMS
Every provider is required to submit a claim for covered services within one year from the date of service.
The role of the physician with respect to home medical equipment:
Every item billed to Medicare requires a physician’s order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required such as copies of office visit notes from prior visits with your physician or copies of test results relevant to the prescription of your medical equipment.
Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating you.
All physicians have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician about your need for medical equipment or supplies before requesting an item from a provider.