Working Rules of Medicare Providers

The history of health insurance in United States dates back to 1850, when Franklin Health Assurance offered the first accident insurance. This company provided insurance for injuries caused due to steamboat and rail road accidents. U.S. President Harry Truman, in his November 1945 address, first proposed a system of public health insurance.

Most children in low income families and senior citizens are covered under the public programs. They, of course, are supposed to meet some eligibility requirements to get enrolled in these programs. Medicare is one such public program designed for people aged 65 or above.

In the United States, Federal government is the Medicare provider for elderly workers, and for individuals who are permanently and totally disabled, person of any age in the end stage of renal disease. As per recent findings, health trends for adults suffering from chronic health problems have improved as they enter the Medicare plan.

What is Medicare?
It is a public Medicare health insurance program run by the federal government to pay for hospital and medical care. Medicare providers have divided the entire health insurance service in four major parts. The two main parts are Medicare Part A (hospital insurance) and Part B (Medical Insurance), and two additional parts Medicare Part C (or Medicare Advantage) and Part D (prescription drug coverage).

• Medicare Part A (hospital insurance)

It pays for all the services that are provided at the hospital including testing, meals, supplies, and a semi-private room. It pays for the medically necessary and part time home health services given to the patient.
It also covers the skilled nursing facilities along with some medical equipment for disabled and the aged like wheelchairs and walkers. The beneficiary is not required to pay monthly premium for Part A coverage, Medicare providers use payroll taxes to cover such costs.

• Medicare Part B (Medical Insurance)

Also known as supplementary medical insurance pays for the necessary medical bills like outpatient hospital visits, physician visits, costs of home health care and other services for disabled and aged people. Part B covers the following:

• Physician and nursing services
• Durable Medical Equipments
• Certain vaccinations
• Laboratory, X-ray and diagnostic tests
• Blood transfusions
• Immunosuppressive drugs
• Certain hormonal treatment
• Renal dialysis
• Chemotherapy

The beneficiaries bear the cost of monthly premium to keep the coverage current and Medicare providers cuts an annual deductible before they start the coverage. Enrollment in Part B is at the discretion of an individual.

• Medicare Part C (Medicare Advantage)

This plan gives flexibility to users to design a plan which is more closely aligned with their specific medical needs. In this, some of the coverage may be provided by private Medicare companies, but the percentage of coverage depends on the eligibility and program taken by the patient.

In some cases this plan can be combined with preferred provider organizations (PPO) or health maintenance organizations to provide specialist preventive health care services. Some of them cater to special needs of patients such as diabetes.

• Medicare Part D

In the year 2006, Medicare providers created a separate section for prescription and put it under Medicare Part D plan. There are many private companies administering Medicare Part D plan and each one of them have covered a different list of drugs and premium costs.

Part D insured people are required to pay for premium and deductibles. The design of the plan is such that it covers 75% of the costs for annual prescription expenditure between $250 and $2,250. From there to up to $2,850 is not covered, but from $3,600 the plan covers 95% of the cost.

Understanding Claims

• Medicare Summary Notice (MSN)

Medicare providers mail the entire covered people a Medicare summary notice every 3 months. It contains details of supplies and services billed to Medicare in the past three months, the amount paid by Medicare, and what the beneficiary is supposed to pay. This summary is just a notice and not a bill.

• Filling for claim

As per the rules in original Medicare, the suppliers and doctors are supposed to file for claims for the supplies and services covered under your plan. Under rare circumstances, the beneficiary will be filling for their own claims.
In case of Medicare advantage plan there is no need for filling for claims as Medicare Providers pays private insurance companies a designated amount each month.

• Review Your MSN

Check your Medicare summary notice for any changes made in the proposed claims. The Medicare provider guides you on the next step to be taken. In case the person owes some extra amount a bill is sent to him or her, and if any amount is due a check is sent or the person account is credited.
In case of any query dial in 1-800-MEDICARE

• Grievances and Appeals

A person has the right to appeal against any decision made under Medicare Services. Appeal can be made irrespective of whether the person is enrolled in original Medicare, prescription drug plan or Medicare advantage plan.
If the person thinks that he is made to pay for an item or service covered under his or her plan than they have the right to appeal against the decision.

• Steps to Review Medicare Summary Notice

If the person has any other insurance, he or she should check if it covers anything excluded from Medicare list. Cross check your bills and receipts with the notice and make sure that all the supplies, services and equipments are listed.

In case the bill is paid before the notice is received, cross check to verify that you have paid the right amount. If any item or service is denied, call your doctor or Medicare provider’s office to make sure they sent the correct information.

Read Complete Guide to Medicare Insurance