Medicare Reimbursement: How It Works

If you’re on Medicare, you know by now that Medicare doesn’t cover everything. You have to meet your deductibles each year, and pay your copays and coinsurance for your doctor visits. There are also some doctors who will charge more than the Medicare-approved amount for services, meaning you’ll have to pay more out-of-pocket to see them. But did you know that you can submit a claim to Medicare to receive some of your money back for some of the care that you receive? So how does Medicare reimbursement work?

Medicare Payment Processhundred dollar bill puzzle

Medicare billing works pretty similarly to that of private health insurance, except that you can see any medical provider, as long as they accept Medicare assignment. As long as they accept Medicare, your medical provider will bill Medicare, who will then pay the agreed-upon rate to the medical provider. You’ll then be left to pay the remaining out-of-pocket costs, or the coinsurance/copay.

But if you see a non-participating provider who does not agree to accept Medicare rates, they can choose to charge more than the Medicare reimbursement amount for services. Medicare allows out-of-network providers to charge up to 15% more than the approved amount for their services, also known as the limiting charge. Whatever rate they charge, you will need to pay the bill out-of-pocket and then file a claim for Medicare reimbursement. 

Original Medicare

If you ever find yourself needing to pay for services upfront, you will need to file a claim with Medicare to get reimbursed. Here’s what you need to know: 

  • The provider has 1 year to submit a bill for their services to a Medicare Administrative Contractor.
  • If the provider does not file within the time limit, you must complete Patient Request for Medical Payment Form 1490S. 
  • You will have to provide itemized bills and a letter explaining why you are submitting a claim.
  • You will receive a Medicare Summary Notice (MSN) in the mail every 3 months, which will outline any claims for reimbursements.
  • Medicare Part B will reimburse 80% of the Medicare-approved amount for the healthcare services you received.

Medicare Supplement Plans

gold piggy bank
A Medicare Supplement Plan can help you save hundreds of dollars a year on medical expenses.

If you want to avoid having to pay for medical services out-of-pocket, you should consider a Medicare Supplement Plan. These plans work with Original Medicare to provide extra coverage for what Medicare doesn’t cover. There are 10 different types of Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Medicare’s Expansion Of Telehealth

Over the past few months, many people have gotten used to seeing their doctor virtually, or being able to call them from the comfort of their own home. Access to telemedicine was greatly expanded during the recent pandemic, and this has been especially beneficial for seniors. Having access to telehealth services means that older adults are not forced to jeopardize their health by going to a doctor’s office, and that they can access care even if they live in rural areas or are unable to get to a doctor’s office.

Now, in order to continue to protect older adults, both CMS and Congress are proposing actions to continue the expansion of telehealth. CMS Administrator Seema Verma announced that telehealth and telemedicine will be expanded to Medicare beneficiaries even after the pandemic is over. “I can’t imagine going back,” said Verma of returning to normal doctor’s visits. Now Medicare beneficiaries won’t have to. Congress is also trying to continue the expansion of telehealth services with their bipartisan Helping Ensure Access to Local TeleHealth (HEALTH) Act. If passed, this bill would mean that community health clinics and clinics in rural areas would continue to get reimbursement for telehealth services.

clack and white picture of congress
CMS and Congress are looking into passing a bill to expand telehealth services for Medicare.

The Temporary Expansion

CMS has been allowing telehealth services to cover more than 100 medical services since the CARES Act was signed into law in March of this year. This piece of legislation included provisions that removed restrictions on a patient’s location when receiving telehealth services, and permitted CMS to waive any Medicare reimbursement requirements.  

Both providers and patients across the country have been taking advantage of the availability of telehealth services since the beginning of the pandemic. Medicare patients have been able to safely access both physical and mental health services throughout these hard times. But as state and federal governments enter their reopening phases, some of the expanded access to telehealth services is beginning to expire.

“Through the temporary telehealth changes thus far, community health center patients have been able to access primary care and behavioral health services while physically distancing to limit spread of coronavirus. However, patients and providers alike will benefit from permanent telehealth access even once the virus is under control,” Chris Shank, CEO and president of the North Carolina Community Health Center Association said in a statement. 

Possible Changes Ahead

As state and federal governments enter their reopening phases, some of the expanded access to telehealth services is beginning to expire. CMS is seeking to stop this expiration and to:

  • Allow telehealth services to be covered under Medicare permanently 
  • Remove “originating site facility and location requirements for distant site telehealth services.” In other words, community health centers and clinics would be able to service anyone in any location.
  • Reimburse community health centers and rural clinics for telehealth services

hundred dollar bills spread out over a white envelope.Congress is also trying to make sure that telehealth is accessible to seniors who could have trouble reaching a provider, as well as to those who receive care through federally qualified health centers. If passed, the HEALTH Act would mean that these community health centers and rural health clinics will continue to be reimbursed by Medicare for telehealth services. The HEALTH Act would provide “permanent cost-related payments for telehealth services furnished by federally qualified health centers [FQHC] and rural health clinics under the Medicare program.”

“The changes that we can make through the standard rule-making process, actions such as adding services to the telehealth list and making those permanent, those will appear in the physician fee rule,” said Emily Yoder, an analyst in CMS’ Division of Practitioner Services, while speaking during the American Telemedicine Association’s virtual conference.

Telehealth has become the new normal, and many Medicare beneficiaries have become dependent on it, especially those who have trouble accessing in-person care. The proposal to expand some telehealth services even after the pandemic is over is a welcome one for seniors who rely on telemedicine to get the care they need.