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7 Essential Rules Of Medicare You Need To Know

If you’re about to turn 65, then you have a lot to look forward to, including finally being able to take advantage of the Medicare benefits that you’ve worked so long for. You probably already know that once you turn 65, you can enroll in Medicare Parts A and B. But if the ins and outs of Medicare are new to you, take a look at our list of the 7 rules of Medicare that you need to know. These rules will help you avoid penalties, prepare you for the costs of Medicare, and allow you to maximize your benefits. 

1. The More You Make, The More You Pay

hand holding a blue bank card
The IRMAA determines how much you will pay for Medicare premiums.

Medicare Part B premiums are generally pretty affordable for most: this year premiums are  $144.60 a month. However, if your income goes above a certain amount, then you will have to pay more in premiums. The income-related monthly adjustment amounts (IRMAAs) determines the amount you will have to pay. Currently, you will face IRMAA surcharges if you earn over $87,000 individually, or $174,000 jointly.

2. Medicare & HSAs Don’t Go Together

Do you have a health savings account (HSA), alongside either employer-based or private insurance? These accounts are great for putting aside pre-tax money for medical expenses. But, once you enroll in Medicare, they can also cause a tax headache for you if you’re not careful. Don’t worry, you can still use the money that is already in your account., but you can no longer contribute to your HSA. If you do, you will face tax penalties on any money you do contribute. 

3. You Can Have Medicare & Private Insurancedifferent sized gears with different kinds of insurance in it

If you are one of the many people 65 and older who decide to keep working and put off retirement, then you may be wondering whether you’ll have to give up your employer-based insurance to enroll in Medicare, or vice versa. No need to worry: if you choose, you can have both private or employer-based health insurance and Medicare at the same time. One will be the primary payer and the other the secondary payer, under a process called coordination of benefits. The rule of thumb when you have both employer-based insurance and Medicare is: if the employer has 20 or more employees, then the group health insurance plan will be the primary payer. If the employer has less than 20 employees, then Medicare will pay first. 

4. You Don’t Need to Be Collecting Social Security to Enroll in Medicare

Waiting to start collecting Social Security could be a smart option for some people: the longer you wait to start collecting, the higher your monthly payments. And, if you’ve decided to wait as long as possible to start collecting SS benefits, you can still enroll in Medicare without any problems.  However, don’t  wait to sign up for Medicare! The longer you wait past your initial enrollment period, the more you’ll have to pay for your Part B premiums.

5. You Can Change Your Coverage

calendar with the date October 15 on it
You can change coverage during the annual enrollment period from October 15 to December 7

Not happy with the coverage you have? You can change it, but only during the annual enrollment period from October 15 to December 7. During this time, you can change from Original Medicare to a Medicare Advantage Plan, or switch your Advantage plan. Just know that if you have Original Medicare and a Medicare Supplement Plan, switching to an Advantage Plan will mean you will lose your Medicare Supplement Plan. Review your plan every year to make sure that it has not changed and still offers the coverage you need. 

6. You Can Dispute a Denied Claim 

Mistakes happen. Sometimes Medicare will deny a claim that they should’ve paid. Medicare processes millions of claims a day, and sometimes there is a billing error or a problem with your coordination of benefits. When this happens, you can absolutely dispute the claim. When you get denied for a claim, you will receive a Medicare Summary Notice (MSN) listing the denied claim/s. You need to file your appeal within 120 days of receiving the MSN.

Do not simply accept that a claim was denied. Ask questions and make sure that your denial was not caused by a clerical error. 

7. Medicare Supplements Will Help You Save MoreCaucasian hand holding a coin over a blue piggy bank

Medicare only pays 80% of Medicare Part B costs; you are responsible for the other 20% out-of-pocket costs. These costs can become a burden for some people – and this is where a Medicare Supplement Plan can come in handy. Medicare Supplement Plans are offered by private insurance companies; you pay a monthly premium, and the plan pays most of your expenses not covered by Medicare Part B. For example, if you have a $4,000 ambulance bill and have already met the yearly Medicare Part B deductible, Medicare Part B will pay 80% of the bill. This leaves you to pay the 20% that is left, $800, out of pocket. But if you have a Medicare Supplement Plan that covers Part B copayments and coinsurance costs, then it will pay the remaining $800.

Are you interested in a Medicare Supplement Plan? There are around 10 different types of Medicare Supplement Plans to choose from, and each offers different coverage at different prices. If you want to pay less in out-of-pocket costs, then a Medicare Supplement Plan is perfect for you. EZ gets how time consuming and frustrating it can be to search for the right plan, so we will offer you an agent that can compare all the available Medicare Supplement Plans in your area, and help you choose the best one for your needs and budget. To get your free quotes, simply enter your zip code in the bar above, or to speak with an agent, call 888-753-7207.

Can Medicare Deny My Claims?

Medicare processes millions of claims each year, and some of them get denied. There can be any number of reasons why claims are denied, ranging from issues with billing codes to not meeting eligibility requirements. People make mistakes so billing errors can also happen.  In these cases,  beneficiaries can appeal the decision, or resubmit the claim. In order to avoid paying out-of-pocket unnecessarily, you should know the reasons why claims are denied and how to go about appealing denials. 

Why Claims Can Get Denied

computer screen with codes on it.
Your healthcare provider’s staff can make a mistake and put in the incorrect billing code.

There are numerous reasons that a Medicare claim can get denied. These include:

  • Billing Errors– Your healthcare provider’s staff can make a mistake and put in the incorrect billing code for a service you have received. When this happens, medicare will deny the claim. For example, the “Welcome To Medicare” visit is covered 100%, but if the code put in reflects a normal visit, and not a covered wellness visit, then you will receive a bill in the mail.
  • Lack of Medical Necessity–  Medicare requires doctors to provide proof that each service they provide is medically necessary. If Medicare does not deem a service necessary, then it will not cover the service. There may be  times when a doctor will consider a service necessary for the patient’s needs, but Medicare might disagree and deny the claim. For example, a doctor may feel that blood work is necessary at a patient’s “Welcome To Medicare” visit. This service, however, is not generally covered by Medicare at this visit and so the claim will be denied.
  • Coordination Of Benefits– If a beneficiary has both an employer-based health plan and Medicare, then coordination of benefits is the process that determines which plan has the payment responsibility. Depending on the size of your employer, that plan will usually be the primary payer and Medicare will usually be the secondary payer. When you stop working or decide to drop your employer’s insurance, Medicare needs to be notified of the change. If Medicare is not notified by your employer, then Medicare will continue to be  considered the secondary payer. Under these circumstances, any services you have that are billed to Medicare will be denied because they will still be considered the secondary payer.

Appealing A Medical Claim Denialhand with a pen in it writing down on a piece of paper.

Denials for services that you feel should’ve been approved can be appealed. There are various legitimate reasons for  appeal, such as billing mistakes. But there are limits on how long you have to file an appeal as well as procedures for how to file correctly. 

When you get denied for a claim, you will receive a Medicare Summary Notice (MSN) listing the denied claim/s. You need to file your appeal within 120 days of receiving the MSN. First, you must circle the item that you are appealing on the MSN and then explain why you think it should be covered. Include any additional information supporting your appeal, including any supporting information  from your doctor.

If your Medicare claim is denied, don’t panic. It could be a simple billing error. However, if you find you are receiving denials for services, make sure you are asking your healthcare provider about coverage at each visit. Your provider should be able to tell you what is covered and what is not and, if they can’t, they will need to provide you with an Advantage Beneficiary Notice of Noncoverage (ABN). This notice informs you that Medicare might not cover the claim, and if you agree to have services, then you agree to pay the non-covered charges. You then have the choice to either sign and receive the service or decline the service. 

You can also call Medicare before receiving services to make sure they will be covered. And, if you do end up receiving a denial, you can always appeal it with supporting information. The more you know about how Medicare makes its decisions about coverage, the more likely you are to get the most out of your plan.

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