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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 Process

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.

Almost Done With Your Medicare “Trial Right”? Want A Different Plan? EZ Can Help

Making the switch from private health insurance to Medicare can be confusing, and even a bit anxiety-inducing. Sure, Medicare is great, but it’s not always easy to navigate if you’re not used to it. There are a lot of little things that people are unaware of when they enroll in Medicare and purchase a Medicare Supplement Plan. For example, did you know that you have a Medicare “trial right”? This right gives you the ability to test out the Medicare Supplement Plan that you’ve purchased, and if you don’t like the plan or it doesn’t work for your needs, you can switch it for another one. But remember, you only have a limited amount of time to do so!

How Long Is Your Medicare Trial Right?

calendar — *You will have 63 days to decide if you want to purchase a Medicare Supplement plan once you’ve switched to Original Medicare.*

You can technically purchase a Medicare Supplement Plan whenever you want, but if you purchase it when you first turn 65, you can avoid the underwriting process. The underwriting process is when the insurer issuing your Medicare Supplement Plan reviews your medical history; they can charge you more for your premiums or deny you coverage based on your health status.

And if you do choose to purchase a Medicare Supplement Plan or even a Medicare Advantage Plan, you have time to try out the plan, known as your trial right. For a Medicare Advantage Plan, you have a full 12 months to try out the plan, and if you think it isn’t right for you, you can switch to Original Medicare and even purchase a Medicare Supplement Plan, as well. The great thing about this trial time is that, even if you choose to switch plans, you can still bypass the underwriting process, and continue to have what is known as a guaranteed issue. You will have 63 days to decide if you want to purchase a Medicare Supplement plan once you’ve switched to Original Medicare.

Now let’s say you purchased a Medicare Supplement Plan when you enrolled in Medicare, but you feel like the plan you chose is not working for you. You will have 30 days to change your plan to a different Medicare Supplement Plan. There are 10 different plans that you can choose from that offer different coverage and premium prices.

Can You Have More Than One Trial Right Period?

Unfortunately, once you exercise your trial right to switch from Medicare Advantage to Original Medicare and a Medicare Supplement Plan, or vice versa, you will not get another chance to switch. If you want to change plans again, you will have to enroll in a Medicare Supplement Plan and go through medical underwriting. However, that does not mean you won’t still be able to find a great, affordable plan! illustration of two people talking

You can work with a Medicare agent to figure out your best option when it comes to your Medicare Supplement Plan, so you can find a plan that covers everything you need covered, and that fits in your budget.

To save as much money as you can, 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 Advantage Vs. Medicare

You’re probably already familiar with Original Medicare, especially if you’re nearing the age of 65 and getting ready to enroll. You may not be aware, though, that there are some gaps in Original Medicare’s coverage, which lead many people to either add a Medicare Supplement Plan or choose a Medicare Advantage Plan. Medicare Advantage Plans, also known as Medicare Part C, are very similar to Original Medicare. However, there is a slight difference between the two, mainly that Medicare Advantage Plans offer more coverage than Original Medicare.

caucasian hand over an older caucasian hand bringing it towards blocks — *Medicare Part B covers physical therapy, doctor visits, and more.*

Original Medicare Overview

Medicare is a government health insurance program consisting of:

Part A– Hospital insurance that covers hospital stays, skilled nursing care facilities, hospice care, and limited home healthcare services.
Part B– Medical insurance that covers preventive services, doctors’ office visits, flu shots, physical therapy, durable medical equipment, diabetes screening and supplies, and mental health care.

In most cases, you will not pay a monthly premium for Medicare Part A; the Medicare taxes that you paid while you were working are what pay for Part A. However, Part A does have a deductible, coinsurance, and co-payments.

Part B, on the other hand, does have a monthly premium: the Medicare Part B premium for 2020 is $144.60, but could be higher depending on your income. Like Part A, Part B also has a deductible, coinsurance, and co-payments for most services. Medicare Part B covers 80% of your costs, meaning you will need to pay the remaining 20% of any bills.

Medicare Advantage Overview

Medicare Advantage is an “all-in-one” alternative to Original Medicare. Private insurance companies approved by Medicare can offer Medicare Advantage Plans. Unlike Original Medicare, most Medicare Advantage Plans include prescription drug coverage, and some plans offer more benefits, like routine dental or hearing care. In order to be eligible for Medicare Advantage, you have to be enrolled in Medicare Part A and Part B. You must also live in the plan’s service area, and you cannot have end-stage renal disease.Medicare Advantage Plan premiums differ from plan to plan. Many Medicare Advantage Plans have low-cost, or even $0, premiums. The average Medicare Advantage premium is only $30 a month. Remember, you will still have to pay your monthly Medicare Part B premiums in addition to any Medicare Advantage premium.

The Similarities

All Medicare Advantage Plans have to offer at least the same benefits as Medicare Parts A and B do. This means that if Original Medicare covers hospital care at a certain level, then so will a Medicare Advantage Plan.

The Differences

The benefit of Medicare Advantage Plans is that they offer more coverage than Original Medicare. The following chart breaks down the differences between the two: