How Does Medicare Reimbursement Work
Medicare allows you to see any doctor you choose, but that doesnt mean all providers handle billing in the same way. Medicare has a schedule of rates it will pay for its covered healthcare services. Those rates are typically much less than a private insurance company would pay.
Most healthcare doctors are participating providers that accept Medicare assignment. They have agreed to accept Medicares rates as full payment for their services.
If you see a participating doctor, they handle Medicare billing, and you dont have to file any claim forms. However, certain doctors dont bill Medicare directly.
If you want Medicare to pay for your care, youll need to send a form to request reimbursement.
Seeing a Non-participating Doctor
These doctors accept Medicare patients, but they havent agreed to Medicares rates. They may choose to accept Medicare rates in your case, or they may decide to bill you up to 15% more than the Medicare rate. The extra charge is an excess charge. Non-participating doctors may bill Medicare directly. But they may also ask you to pay up-front and seek reimbursement from Medicare.
Foreign Travel Care Reimbursement
Receiving care outside the United States that is covered by Medicare. In general, Medicare doesnt pay for services in foreign countries. But there are a few exceptions where you can file a claim and get reimbursement for your costs.
Improper Provider Billing
If you are close to the deadline, you can seek reimbursement.
What Are Important Medicare Decisions
Applying for Medicare Parts A and B is the first step. Other decisions related to Original Medicare can be made in the same timeframe:
- Should you enroll in Medicare Part D, which will cover the cost of your medications?
- Should you buy Medicare Supplement to cover expenses that arent included in Original Medicare?
- Should you replace Original Medicare with Medicare Part C ?
Working At A Large Company
The general rule for workers at companies with at least 20 employees is that you can delay signing up for Medicare until you lose your group insurance .
Many people with large group health insurance delay Part B but sign up for Part A because it’s free.
“It doesn’t hurt you to have it,” Roberts said.
However, she said, if you happen to have a health savings account paired with a high-deductible health plan through your employer, be aware that you cannot make contributions once you enroll in Medicare, even if only Part A.
Also, if you stay with your current coverage and delay all or parts of Medicare, make sure the plan is considered qualifying coverage for both Parts B and D.
If you’re uncertain whether you need to sign up, it’s worth checking with your human resources department or your insurance carrier.
“I find it is always good to just confirm,” said Elizabeth Gavino, founder of Lewin & Gavino and an independent broker and general agent for Medicare plans.
Some 65-year-olds with younger spouses also might want to keep their group plan. Unlike your company’s option, spouses must qualify on their own for Medicare either by reaching age 65 or having a disability if younger than that regardless of your own eligibility.
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What If I Cant Get Copies
You should submit your application even if you dont have copies of some of these documents. Social Security might be able to help you track them down.
In fact, Social Security can often request copies and verification from your states Bureau of Vital Statistics. If not, it can help you get the forms you need in order to get the documents yourself.
The way you enroll in Medicare depends on which parts of Medicare you choose. There are different methods for enrolling in original Medicare as opposed to Medicare Advantage , Medigap, and Part D plans.
What Other Times Can You Sign Up
You may also become eligible for Medicare for other reasons. If youre eligible due to a disability, you qualify after youve received Social Security disability or certain Railroad Retirement Board disability benefits for 24 months.
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The Problem With Missing Your Enrollment Deadline
Most Medicare enrollees don’t pay a premium for Part A, which covers hospital visits. However, they do pay for Part B, which covers preventative care and diagnostic services. Currently, the standard Part B premium is $134 . If you don’t sign up for Medicare during your initial enrollment window, you’ll face a 10% increase in your Part B premiums for every year-long period you’re eligible for coverage but don’t enroll. Therefore, it generally pays to sign up for Medicare at 65 — unless you happen to qualify for one major exception.
How Social Security Benefits Can Affect Medicare Enrollment
If you are receiving Social Security benefits when you turn 65, youll be automatically enrolled in Medicare Parts A and B, even if youre working. Your Medicare card will arrive in the mail about 3 months before your 65th birthday.
Once youre enrolled in Medicare, a monthly Part B premium will be automatically deducted from your Social Security check. If you dont want Medicare Part B, you need to notify Medicare to opt out. There will be instructions for doing this on the back of your Medicare card.
If youre not receiving Social Security or Railroad Retirement Board benefits, you will need to enroll yourself in Medicare when you become eligible.
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Do You Have To Sign Up For Medicare When Youre 65
As long as you have creditable coverage, you dont have to enroll in Medicare when you are 65. Technically, you dont have to sign up for Medicare at all if you dont want to. Medicare is not mandatory, but it is important to be aware that if you choose to sign up later without creditable coverage, youll incur penalties that you may be stuck with for the rest of your life.
The most common reason a new beneficiary may delay enrolling in Medicare is that they have coverage through their employer. However, not all group coverage is creditable coverage. The size of your employer will determine if the coverage is creditable.
How Do I File A Complaint With A Medicare Advantage Plan Or A Medicare Part D Plan
If you have a complaint about your Medicare Advantage plan or Medicare Part D prescription drug plan, contact your plan carrier directly or follow the plans instructions for filing a complaint located in your plans membership materials.
Because these plans are sold by private insurers, each plan may have its own protocol for filing a formal complaint.
You may also submit an official Medicare Complaint Form to file your complaint with Medicare. Medicare uses information from these complaint forms to monitor and improve the quality of private Medicare plans.
Complaints about a Medicare prescription drug plan must be filed within 60 days of the event that led to the complaint, and the beneficiary must be notified of the decision no later than 30 days after filing the complaint.
If the complaint involves a plans refusal to make a timely coverage determination and you have not yet purchased the drug as a result of their delay, the plan must grant you a decision within 24 hours of filing the complaint.
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Are There Other Key Dates To Know
If someone did not sign up for Medicare Part B during their Initial Enrollment Period, they could apply during a General Enrollment Period that runs from .
If a person signs up during this time, their Medicare benefits will start on July 1 of the same year.
A Medicare Advantage Open Enrollment Period is also available between the same dates, during which a person can make one change to their Medicare coverage.
Such a change might involve switching from one Medicare Advantage plan to a different plan or returning to Traditional Medicare.
However, a person cannot switch from Original Medicare to Medicare Advantage during this time.
Penalty Fees For Late Enrollment
Medicare charges penalty fees for those who do not enroll in their Initial Enrollment Period, or they do not qualify for an exception due to employer insurance or other coverage.
Unless a person qualifies for a special exception, they will pay a monthly premium that is 10% higher for every 12-month period they were eligible for Medicare but did not sign up.
A person can qualify for a Medicare plan before 65 years of age if they meet certain criteria:
- They have end stage renal disease and need dialysis or are on the kidney transplant list.
- They have amyotrophic lateral sclerosis .
- Their doctor confirms that they have a disability.
An estimated 6.2 million people qualify for Medicare because they are disabled, according to the Medicaid and CHIP Payment and Access Commission. However, significantly fewer people use these benefits.
A doctor may declare a disability for people due to several types of medical conditions, including:
- Intellectual or developmental disabilities: These might include Down syndrome, cerebral palsy, or autism.
- Physical conditions: Traumatic brain injury, severe back injuries, or quadriplegia qualify as disabilities.
- Severe behavioral or psychological disorders: People with bipolar disorder or schizophrenia can qualify for Medicare early.
A doctor must submit paperwork to Medicare, declaring that a person has a disability. The individual may have a waiting period before they qualify for full Medicare benefits.
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Im Working Past 65 But My Health Coverage Is From My Spouses Employer
A pretty common situation to face, if your health care coverage is from a spouses employer, you may be able to delay Medicare or you may need to enroll when you first become eligible. In this case, the employer still needs to have 20 or more employees. However, the big difference is that employers can have rules for covered dependents 65 and older that may require the individual to get Medicare at 65 in order to remain on the employer plan.
Therefore, if you have employer coverage through a spouses employer, you need to ask the employers benefits administrator directly about your Medicare enrollment choices.
Top 5 Things You Need To Know About Medicare Enrollment
1. People are eligible for Medicare for different reasons.
Some are eligible when they turn 65. People under 65 are eligible if they have received Social Security Disability Insurance or certain Railroad Retirement Board disability benefits for at least 24 months. If they have amyotrophic lateral sclerosis , theres no waiting period for Medicare. Some people with End Stage Renal Disease may be eligible for Medicare. Its important to know the different ways that people qualify for Medicare so you can help current and former employees and their dependents anticipate their eligibility for Medicare so they can make timely and appropriate decisions about their enrollment.
People living in the United States and U.S. Territories who are already collecting Social Securityeither disability or retirementare automatically enrolled into Part A and Part B when theyre first eligible. These people will get a packet of information a few months before they turn 65 or receive their 25th month of Social Security Disability or Railroad Retirement Board benefits. At that time, they can choose to keep or decline Part B, but cant decline Part A unless they withdraw their original application for Social Security and pay back all Social Security cash benefits.
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How To Apply For Medicare Part A And Part B Before Age 65
Some people are automatically enrolled in Original Medicare. If youve been receiving disability benefits from Social Security or the Railroad Retirement Board for 24 months in a row, you will be automatically enrolled in Original Medicare, Part A and Part B, when you reach the 25th month.
If you have ALS or Lou Gehrigs disease, youre automatically enrolled in Medicare the month you begin receiving your Social Security disability benefits.
Some people will need to sign up for Medicare themselves. If you have end-stage renal disease , and you would like to enroll in Medicare Part A and Part B, you will need to sign up by visiting your local Social Security Office or calling Social Security at 1-800-772-1213 . If you worked for a railroad, please contact the RRB to enroll by calling 1-877-772-5772 , Monday through Friday, 9 AM to 3:30 PM, to speak to an RRB representative.
What Should I Do If My Provider Doesnt File My Claim
Before receiving care, ask your providers office whether they will submit your bill to Original Medicare. While they arent required to do so, some non-participating providers will still file your claims with Medicare.
The same situation applies for Medicare Advantage enrollees who see out-of-network providers. These providers dont have to file claims with your Advantage plan, but may choose to do so.
If you have Original Medicare and a participating provider refuses to submit a claim, you can file a complaint with 1-800-MEDICARE. Regardless of whether or not the provider is required to file claims, you can submit the healthcare claims yourself. You can file an Original Medicare claim by sending a Beneficiary Request for Medical Payment form and the providers bill or invoice to your regional Medicare Administrative Contractor . Keep copies of everything you submit.
, Home Health Advance Beneficiary Notice, or Skilled Nursing Advance Beneficiary Notice if they believe Medicare will not cover your care. Providers normally will not bill Medicare after they issue an ABN.
You have the right to demand bill, which is when you demand that the provider or facility submit a claim to Medicare for your care. In order to demand bill, you must sign the ABN and agree to pay the charges if Medicare denies coverage. Demand billing can be used to generate a formal Medicare coverage denial, which gives you further appeal rights.)
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Compare Medicare Advantage Plans In Your Area
To learn more about the types of Medicare Advantage and Medicare prescription drug coverage options that may be available where you live, you can call to speak with a licensed insurance agent.
While a licensed insurance agent cant help you with a complaint about your current plan, they can help you compare the costs, benefits, coverage and more for plans that are available in your area.
You can also compare plans online for free, right from the comfort of your own home.
Compare Medicare plans
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
About the author
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.
Where you’ve seen coverage of Christian’s research and reports:
For California residents, CA-Do Not Sell My Personal Info, .
Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.
Medicare has neither reviewed nor endorsed this information.
I Turn 65 In A Few Months When Should I Sign Up For Medicare
En español | If you already receive Social Security benefits, Social Security will automatically sign you up for Medicare Part A and Part B though you can decline Part B enrollment if you want to. Otherwise, you need to apply for Medicare. The best time to do that depends entirely on your own situation. Broadly, there are two options:
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Do You Need To Apply For Medicare
Most people do need to apply for Medicare. But if you reach age 65 and youre already receiving retirement benefits from Social Security or the Railroad Retirement Board, youll be signed up for Medicare Part A and Part B automatically.
And if you arent receiving retirement benefits and you dont have health coverage through an employer, you will need to apply for Medicare as you approach age 65. If you need to apply, Medicare gives you several options.
Advantages Of The Initial Signup Period
The initial signup period is the ideal time to study and select the best combination of Medicare programs.
Enrolling when first eligible avoids late fees and restrictions that can come from applying at later times. The initial signup is best for Medigap insurance, Part D Prescription Drug coverage, and Part C Medicare Advantage.
When applying online, doing so at the first opportunity will help you to get the combination of benefits and coverage that suits your needs.
Typical combinations include:
- Original Medicare , with Prescription drug insurance .
- Original Medicare , with a Medigap policy, as well as Prescription drug insurance .
- Medicare Advantage , especially when offered with built-in prescription coverage, known as MAPD plans.
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Medicare Part D Enrollment Deadlines
For people who need a lot of prescriptions or those with costly prescriptions, a Medicare Part D drug plan may help offset the cost of monthly prescriptions. The enrollment guidelines for Medicare Part D are similar to those for Medicare Part C or Advantage Plans. You have the seven-month period surrounding your 65th birthday to enroll in Part D coverage. But you can also add this coverage later, under certain conditions. Lets return to Janice Dowry to see how she might enroll in a Medicare Part D drug plan.
- Since enrolling in Parts A and B, Janice has developed a chronic condition that requires costly prescriptions. She decides to enroll in a Part D plan to offset the cost of her medical care.
You should also keep in mind that the Medicare Advantage Open Enrollment period is reserved specifically for disenrolling from Medicare Advantage or switching to a new MA plan. It cannot be used to modify or cancel a Medicare Part D plan. You can only switch Part D plans during the allotted period.