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Part B reimbursement MAPD beneficiaries
The reimbursement for Medicare Advantage plans follows a process (depending on your healthcare plan) which, if not adequately understood may pose certain difficulties to beneficiaries.
Generally, beneficiaries do not need to submit claims to Medicare to get reimbursed. In most cases, all through the validity of the plan, you don’t need to pay upfront for your healthcare needs, rather you make cost-sharing payments such as coinsurances and deductibles.
For beneficiaries with Original Medicare, they do not have to worry about filing claims for reimbursement. But this doesn’t apply to Medicare Advantage and Medicare Part D beneficiaries because the rules regulating them are different.
HOW DOES IT WORK?
Under the Medicare Part A and Part B plans, your plan providers send claims directly to Medicare without you seeing any bill whatsoever.
Basically, you make payments for your Medicare Part A and Part B coinsurances or copayments as well as your Part A & Part B deductibles.
However, in some cases, you do not get to pay upfront for the whole medical service before getting to file for reimbursement.
Medicare providers and suppliers must send their claims to Medicare, so it’s typically the providers and suppliers who have to file for reimbursement.
The centers for Medicare and Medicaid (CMS) sets reimbursement rates for all services and equipment provided to Medicare beneficiaries and gets to offset them based on approved guidelines such as the Physician-Fee-Schedule. In some cases, you may need to file a Medicare claim.
When a provider accepts an assigned beneficiary, they agree to accept Medicare-established fees. Your plan provider cannot charge you for the difference in their regular rates and the Medicare set fees.
Most Medicare payments are forwarded to providers of Part A and Part B-covered services. Bear in mind that the costs for coinsurances, copayments, and deductibles will still be covered by you.
There are occasions where you will need to pay for medical services at the time of service and file for reimbursement. In such instances, your health care provider isn’t Medicare-assigned, so you’ll need to pay for the service or supply and file for reimbursement.
However, if a provider or supplier accepts Medicare assignment, that means such a provider has an agreement with Medicare to accept Medicare-approved payment for that particular service or supply, and will not have to charge you any additional fees, though you still need to pay any coinsurance, copayment or deductible that may apply.
HOW TO FILE FOR REIMBURSEMENT
Filing for Medicare reimbursement claim when you have Original Medicare (Part A & Part B) and the plan provider is a participating provider, is quite rare. You can look out for outstanding claims by checking your Medicare Summary Notice (mailed quarterly) or by checking online www.MyMedicare.com
Here is a step by step process on how to file for reimbursement:
- Medicare claims must be filed within a year of the date of service
- Start the process by asking your provider or supplier to file the Medicare claims on your behalf
- If you (or your provider) fail to file the claim by the deadline date, fill out the Patient Request of Medical Payment form (CMS-1490S), you can download it from www.medicare.gov. Make sure you follow the instructions on the form religiously.
- Fill out the form by carefully following the instructions provided. Explain in detail why you are filing a claim (doctor’s failure to file, supplier billed you, etc.) and provide the itemized bill with the provider’s name and address, diagnosis, the date and location of service (hospital, doctor’s office) and description of services.
- Provide any relevant information that you think will be helpful to aid the reimbursement process.
- If you need help or have questions concerning Medicare reimbursement, call a Medicare ombudsman on 1800-633-4227 OR contact your State Health Insurance Assistance Program (SHIP).
- Lastly, if you need to designate someone else to file the claim or talk to Medicare for you, you will have to fill out the “Authorization to Disclose Personal Health information” form.
Note also that, you cannot file a claim if you visit an opt-out doctor. You will be responsible for the whole charge, except for emergency care.
To be eligible to receive reimbursement, you must maintain your Medicare Part B coverage. If you or your dependants discontinue Medicare Part B for any reason during the year, you must notify your provider immediately.
Because Medicare Part B reimbursement payments are tax-exempt, your provider is legally required to collect any reimbursement payments made after you discontinue your Medicare Part B coverage. You will be required to repay the total amount of reimbursements made to you that you were ineligible.
MEDICARE REIMBURSEMENT FOR MEDICARE ADVANTAGE PRESCRIPTION DRUG (MAPD) BENEFICIARIES.
Since Original Medicare does not provide coverage for prescription drugs that you take home, you will need to enroll in a stand-alone Medicare Prescription Drug Coverage Part D to enjoy Part D benefits.
Alternatively, you can enroll in a Medicare Advantage Prescription Drug plan as a way of receiving your Original Medicare benefits, thereby getting all of your Medicare coverage through a single Plan.
Basically, Medicare Part D prescription drug coverage is provided through private insurance plans. Each plan has specific rules or a list of drugs are that it covers. These rules or lists are called a formulary and what you pay is based on a tier system that includes:
- Tier 1 – preferred Generic Medication (Lowest cost)
- Tier 2 – preferred brand name medications (highest cost)
- Tier 3 – preferred brand name medications
- Tier 4 and higher – specialty, select, high cost medications
Note that, medications on a tier system can vary based on your preferred plan, so it’s good to know where your medications fall within the tier system of the specific plan you are considering.
The drug store where you fill your prescriptions will file your claims for covered medications. You will however be required to pay the copayment and any co-insurance.
If you personally make a payment for a medication, you cannot file a claim with Medicare, so any claims made will be filed with your insurance provider.
WHY DO I NEED TO FILE CLAIMS FOR MEDICATIONS?
There are certain reasons why you may need to file a claim for Part D Medications, these reasons include:
- You made payments for a vaccine that is covered
- You ran out of medications while out of your plan’s network area and had to purchase them.
- You received medications at an outpatient surgery, emergency room or clinic by an out-of-network pharmacy during your observation status.
- You couldn’t have access to your medications due to a serious disaster or federal/state emergency and had to purchase them.
In cases where a particular drug is not covered or it cost way higher than you expect, you may need to inquire from your provider about coverage. However, if you have made payments for a medication, you can ask for a reimbursement by filling out a Model Coverage Determination Request Form.
But if you haven’t made payments for the medication, you can ask your plan provider for a coverage termination or an exception to have the medication covered. Also, you can file an appeal in writing to get the medication covered or get your doctor to do that for you.
When filing for reimbursement claims for MAPD, it is advisable to call the plan and ask how to file a claim. Always keep a track of all your pending claims by reviewing your Medicare Summary Notice via mail or online.