In Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). , the term improper billing refers to a provider See Health Care Provider. inappropriately billing a beneficiary A beneficiary is a person who receives benefits. If you are a member of a health plan, like a group health plan, Original Medicare, or Medicaid, and receive benefits from that plan, you are a health plan beneficiary. for Medicare cost-sharing. Cost-sharing can include deductibles, coinsurance, and copayments. Federal law prohibits Medicare providers from billing people enrolled in the Qualified Medicare Beneficiary (QMB) program for any Medicare cost-sharing. This means that if you have QMB, Medicare providers should not bill you for any Medicare-covered services you receive.
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[glossary_exclude]Each state offers a State Health Insurance Assistance Program (SHIP), partly funded by the federal government, to give you free counseling and assistance. A SHIP counselor may be available by phone or in person.[/glossary_exclude]
Visit www.shiptacenter.org to find your local SHIP office.
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More specifically, if you have QMB and are enrolled in Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , you should not be billed when receiving a Medicare-covered service from either:
- A participating provider (one who takes assignment Assignment is Medicare’s approved amount for a service or item. Original Medicare pays 80% of this amount and you (or your supplemental insurance) are responsible for the remaining 20%, called a coinsurance. See also: Take Assignment, Participating Provider, and Non-Participating Provider. )
- A non-participating provider In Original Medicare, a non-participating provider is a health care provider that accepts Medicare but does not take assignment in all cases. You may pay up to 15% of Medicare’s approved amount for the service, in addition to the 20% Medicare coinsurance. The provider can request full payment up front, then submit the bill to Medicare for reimbursement. See also: Participating Provider.
If you have QMB and are enrolled in a Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Â Plan, you should not be billed when receiving a plan-covered service from:
- In-network providers, as long as you meet your plan’s coverage rules, such as getting to see certain specialists
To protect yourself from improper billing, be aware that:
- Original Medicare and Medicare Advantage providers who do not accept Medicaid must still comply with improper billing protections and cannot bill you
- You keep your improper billing protections even when receiving care from Medicare providers in other states (Note: You can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. provider, or if you have Original Medicare and see an opt-out Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. They can charge whatever they want for services, and Medicare will not pay for care you receive from an opt-out provider (except in emergencies). The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you. provider)
- You cannot choose to waive these protections and pay Medicare-cost sharing, and a provider cannot ask you to do this
Remember that if you have QMB, the Medicare providers you see must accept Medicare payment and any QMB payment as the full payment for any Medicare-covered services you received. Providers who violate improper billing protections may be subject to penalties. If you are having issues with a provider who continually attempts to bill you, or if you have unpaid cost-sharing bills that have been sent to collection agencies, call 1-800-MEDICARE or contact your Medicare Advantage Plan.
Note: Some states may impose Medicaid copays for certain Medicare-covered services. Medicare and Medicaid should pay the majority of the cost, leaving you a nominal copay. Contact your local Medicaid office to learn more about Medicaid copays in your state.