Important Information About Medicare
We hope you find the answers to your questions here, but if not please call 760-773-1342. You can also visit Medicare's Official Website - www.medicare.gov or call 1-800-MEDICARE.
- Why am I billed for some of the medication I am given while receiving services at the hospital as an outpatient?
- What is the purpose of an Advanced Beneficiary Notice (ABN)?
- If Medicare will not pay for a test, does that mean I do not need the test?
- Why am I asked to complete a Medicare Secondary Payor Questionnaire?
- How does Medicare cover outpatient services?
- Is there some place that I can get additional information concerning my coverage by Medicare?
- What do I need to Know about the MMA-Medicare Approved Drug Discount Cards and Transitional Assistance Plan?
1. Why am I billed for some of the medication I am given while receiving services at the hospital as an outpatient?
During the course of your outpatient treatment, you may be given medication that is considered self-administrable by Medicare. Self-administrable drugs are defined by Medicare as medications that the patient could, in another setting, take him or herself. The list of medications includes tablets, sprays, drops, inhalants and some common injectable drugs.
In order to remain compliant with Medicare regulations related to the billing of these drugs, medical providers are required to submit these self-administrable drugs as non-covered items on our billing to Medicare.
You will receive a bill from the hospital following payment of our claim by Medicare. In addition to any deductible and co-insurance due, this bill will reflect the charges for unpaid self-administrable drugs. Payment for non-covered items will be expected from you. With few exceptions, most secondary insurance carriers do not cover self-administrable drugs.
Please review your Medicare Beneficiary Handbook for information on coverage of medications dispensed on an outpatient basis. To obtain additional information on this subject, please contact the Medicare Beneficiary Help Line at (540) 985-3931.
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2. What is the purpose of an Advanced Beneficiary Notice (ABN)?
Medicare has established guidelines to ensure that all tests or procedures performed on Medicare beneficiaries are medically necessary.
When your physician writes an order for a test, he or she includes the diagnosis or reason for the test on the order. After the test is completed, the hospital will bill Medicare for payment. Medicare requires that all claims submitted on behalf of a Medicare beneficiary include the type of test and the medical reason for the test. If the diagnosis does not meet Medicare’s established criteria for medical necessity, payment for the claim will be denied.
It is our responsibility, as the provider of care, to notify our patients prior to testing if the diagnosis supplied by the physician does not meet Medicare’s medical necessity guidelines. In these cases, the patient will be asked to sign an Advance Beneficiary Notice acknowledging that the patient is aware that Medicare may not pay the claim and accepts financial responsibility for payment.
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3. If Medicare will not pay for a test, does that mean I do not need the test?
No. Your doctor bases decisions about testing on a wide range of factors including such things as your personal medical history, any medications you might be taking and generally accepted medical practices. Even if your doctor believes a test will provide useful information in order to give you the best care, it is possible that Medicare may not consider the test to be medically necessary for your diagnosis.
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4. Why am I asked to complete a Medicare Secondary Payor Questionnaire?
Medicare requires that medical care providers obtain certain types of information from Medicare beneficiaries each time a test or procedure is performed.
Your responses to the questions are used by Medicare to ensure appropriate assignment of payment liability. In other words, Medicare should not be billed for charges that may be the responsibility of another payment source. For example, if you were seeking treatment for an automobile accident, any accident insurance would need to be billed prior to billing Medicare.
Some of the information collected on this questionnaire is maintained in your permanent Social Security record and each claim submitted on your behalf is matched to this record. We understand that answering these questions each time you are treated can be an inconvenience, however, it is extremely important that we adhere to Medicare requirements and that we submit the most accurate information available.
We appreciate your assistance and understanding as we endeavor to comply with Medicare’s claim requirements.
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5. How does Medicare cover outpatient services?
Effective with service provided 08/01/00 and beyond, Medicare has implemented a new method of reimbursement to hospitals for outpatient services. This new method is referred to as Ambulatory Payment Categories (APCs) or OPPS (Outpatient Prospective Payment System).
Previously, most outpatient services were paid by Medicare based on a percentage of the charges submitted by the hospital for your testing or treatment. Your co-payment was assessed at 20% of the submitted charges. Under APC claim processing, Medicare assigns a flat payment amount to certain outpatient services and your co-payment is assessed at 20% of the assigned payment amount. For some services your co-payment could be higher under APCs than when co-payments were calculated at 20% of billed hospital charges.
A co-payment Under APCs cannot exceed the amount of the Medicare inpatient deductible of $912.00.
We will continue to bill your secondary insurance for the balance after Medicare satisfies their portion of the claim.
APC payment methodology will have no impact on your treatment at Eisenhower Facilities.
All Medicare requirements for medical necessity and MSPQ will remain in effect.
You will notice a difference in the appearance of your Medicare Summary Notice. Paid APCs will be listed individually for you.
Medicare has established a help line at (800) 633-4227 to assist you with any questions.
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6. Is there some place that I can get additional information concerning my coverage by Medicare?
Yes. You can call 1-800-MEDICARE or visit www.medicare.gov to get help with your Medicare questions.
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7. MMA-Medicare Approved Drug Discount Cards and Transitional Assistance Plan
The Drug Discount Card and Transactional Assistance Program is the first phase of the Medicare Prescription Drug Improvement and Modernization Act of 2003.
The roll out of the complete program is scheduled for 2006. In the interim, the Drug Discount Card Program and Transitional Assistance Program will provide benefits for eligible Medicare beneficiaries. Enrollment began May 2004 and will continue through the year for the drug discount card part of the program.
Transitional Assistance provides a $600 credit toward the purchase of prescription drugs. In order to qualify, a beneficiary must meet certain income requirements based on the Federal Poverty Guidelines. A small coinsurance payment for individual prescriptions will apply based on the income level of the beneficiary. The beneficiary can not receive out patient pharmacy benefits from another source including Tricare or state medical assistance programs.
Beneficiaries can be eligible for the $600 credit and a discount card.
In order to apply for this program and to obtain information about other pharmacy assistance programs, call 1-800-MEDICARE.
There are no income requirements for the Drug Discount Card. A beneficiary must be entitled to Part A or enrolled in Part B (or both) benefits. A beneficiary can only enroll in one discount drug card at a time. Companies offering drug cards can not charge an enrollment fee greater than $30. Drugs can be provided by mail but the network must provide benefits at pharmacies in the locality where the beneficiary resides.
Benefits will vary by card sponsor/vendor including the drugs that are offered under the discount. Special discounts may be provided for generic drugs and some cards may offer a discount on over-the-counter medications.
After the initial enrollment in 2004, the beneficiary will have the option of choosing a different card between November 15 and December 31, 2004.
All Medicare approved discount cards will have a MEDICARE APPROVED symbol on the front of the card.
For additional information about this program call 1-800-MEDICARE or go to www.medicare.gov
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