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Getting Reimbursed by Medicare


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You generally don’t have to submit claims to Medicare and get reimbursed. In most cases you don’t pay up front for all your health care; you make cost-sharing payments such as coinsurance and deductibles.

Here’s a quick overview of the way payment works in the various parts of Medicare.

Medicare reimbursement for Original Medicare (Part A and Part B)

Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Under this program, your Medicare providers send your claims directly to Medicare, and you won’t see a bill. Typically, you pay coinsurance or a copayment for Medicare Part A and Part B services, as well as Part A and Part B deductibles. But in most cases, you don’t have to pay for the entire medical service up front and 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 & Medicaid Services (CMS) sets reimbursement rates for Medicare providers and generally pays them according to approved guidelines such as the CMS Physician Fee Schedule.

Sometimes you may need to file a Medicare claim

There may be occasions when you need to pay for medical services at the time of service and file for reimbursement. For example, if your health-care provider isn’t “Medicare-assigned,” you might have to pay for the service or supply and file for reimbursement. If a provider or supplier accepts Medicare assignment, that means he or she has an agreement with Medicare to accept the Medicare-approved payment for that service or supply, and not bill you an additional amount. (You still pay any copayment, coinsurance, or deductible amount that may apply.)

Some health-care providers are considered “participating” providers; they accept Medicare assignment for all Medicare-covered services. “Non-participating” providers can still decide to accept Medicare assignment for individual services.

Note: If you visit a doctor who doesn’t accept Medicare assignment, you might have to pay the entire cost at the time of service; however, the provider can only charge you up to 15% more than the Medicare-approved cost of the service in most cases.

If you use a medical supplier who doesn’t accept Medicare assignment, your costs might be higher, and the limiting charge might not apply. See Medicare’s supplier directory for more information.

To avoid having to pay up front, possibly more than the Medicare-approved amount, make sure your health-care provider or supplier accepts Medicare assignment. You can ask the provider or supplier if he or she is Medicare-assigned, or ask Medicare (contact information is at the bottom of this page). You can also use Medicare.gov’s Physician Compare tool to find doctors participating in the Medicare program. If you like, you can even filter your search to only show doctors who accept assignment.

If you do need to file for reimbursement from Medicare:

  • Note that in most cases, Medicare claims must be filed within a year of the date of service.
  • Start by asking the provider or supplier to file the Medicare claim on your behalf.
  • If for some reason you need to file the claim (for example, if the provider doesn’t file it by the deadline), fill out the Patient Request for Medical Payment Form (CMS-1490S). Be sure to follow the instructions on the form.
  • If you need help or have questions, you can talk to a Medicare ombudsman either by calling Medicare (contact information at the bottom of this page) or by contacting your State Health Insurance Assistance Program(SHIP).

Medicare reimbursement for Medicare Advantage (Part C)

Medicare Advantage plans contract with Medicare to provide your Part A and Part B benefits. Medicare pays these plans a certain monthly amount. You generally don’t need to file a claim. However, be aware that some types of Medicare Advantage plans, such as Health Maintenance Organizations (HMOs), may require you to visit the plan’s network providers. If you go to a provider outside the plan’s network, you might have to pay for the service received in full (except in medical emergencies).

If you have questions about how your plan works, contact your plan. You should have a card from the plan with contact information. If you can’t find your card, you can call Medicare (contact information at the bottom of this page).

Medicare reimbursement for Medicare prescription drug coverage (Part D)

Original Medicare does not typically cover prescription drugs you take at home. If you want this kind of coverage, you need to enroll in a stand-alone Medicare Part D Prescription Drug Plan. Or you can enroll in a Medicare Advantage Prescription Drug plan as an alternative way to get your Original Medicare benefits, and thus get all of your Medicare coverage through a single plan. You still need to pay your monthly Medicare Part B premium, in addition to any premium the Medicare Advantage plan may charge.

If you have a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan that doesn’t cover a prescription medication your doctor prescribes, you can file an appeal. However, you might first want to speak with your doctor to see if any prescription drug your plan does cover can be substituted.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

 

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