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State Medicare Guidelines
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 BILLING AND REIMBURSEMENT
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Frequently Asked Questions
This information is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current, the information may not be as current or comprehensive when you view it. Please consult with your counsel or reimbursement specialist for any reimbursement or billing questions.
Whether you are experienced or new to reimbursement, there is a lot to know. This section answers some common reimbursement questions. If you have other questions, you can call us at 1-888-ACCESS-1 (222-3771) and we will assist in finding your answer.
Medicare Frequently Asked Questions / Talking Points
What's the difference between Medicare Part A and Medicare Part B?
Medicare Part A helps pay for hospital inpatient care, limited skills nursing facility care, and some home health care. Payment for services delivered in Part A covered settings is typically all-inclusive; therefore, REMICADE is not usually paid separately when administered in these settings. Most Medicare beneficiaries automatically receive Part A and do not have to pay a monthly premium because they or a spouse paid Medicare taxes while working.
Medicare Part B helps pay for physician services, outpatient hospital care, and some medical services not covered by Part A, such as physical and occupational therapy. Medicare Part B is an optional benefit for those eligible for Medicare. In addition to a yearly deductible ($135 for 2009), enrollees in Medicare Part B pay a monthly premium to help cover the cost of the program. Because REMICADE is typically administered in a physician's office and is covered by the Part B benefit when deemed medically necessary, it is subject to the $135 deductible and 20% coinsurance.
Effective January 1, 2008, Part B premiums will continue to be based on income. The following table provides the Medicare Part B premium rates for beneficiaries.
2009 Part B PREMIUMS
| Beneficiaries who file an individual tax return with income |
Beneficiaries who file a joint tax return with income |
Income-related monthly adjustment amount |
Total monthly premium amount |
| Less than or equal to $85,000 |
Less than or equal to $170,000 |
$0.00 |
$96.40 |
| Greater than $85,000 and less than or equal to $107,000 |
Greater than $170,000 and less than or equal to $214,000 |
$38.50 |
$134.90 |
| Greater than $107,000 and less than or equal to $160,000 |
Greater than $214,000 and less than or equal to $320,000 |
$96.30 |
$192.70 |
| Greater than $160,000 and less than or equal to $213,000 |
Greater than $320,000 and less than or equal to $426,000 |
$154.10 |
$250.50 |
| Greater than $213,000 |
Greater than $426,000 |
$211.90 |
$308.30 |
The monthly premium rates paid by beneficiaries who are married, but file a separate return from their spouses and who lived with their spouses at some time during the taxable year, are different. Those rates are as follows:
| Beneficiaries who are married, but file a separate tax return with income |
Income-related monthly adjustment amount |
Total monthly Part B premium amount |
| Less than or equal to $85,000 |
$0.00 |
$96.40 |
| Greater than $85,000 and less than or equal to $128,000 |
$154.10 |
$250.50 |
| Greater than $128,000 |
$211.90 |
$308.30 |
Updated: 5/19/09
What is Medicare Advantage?
Medicare Advantage (formerly Medicare + Choice) Plans generally provide all Medicare-covered services through a specific plan such as an HMO or PPO. Medicare Advantage Plans are available in many areas and typically provide health care coverage that exceeds the coverage of traditional Medicare. Sometimes referred to as “Medicare Replacement” or “Medicare Part C,” these plans must offer benefits that are the same or better than those offered through traditional Medicare. However, you may need to see doctors that belong to the plan or certain hospitals to get services.
Updated: 02/21/07
How do I enroll in a Medicare Advantage Plan?
To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer.
If you’re in a Medicare Advantage Plan, you don’t need a Medigap policy because Medicare Advantage Plans generally cover many of the same benefits that a Medigap policy would cover, like extra days in the hospital after you have used the number of days paid for by Medicare.
The Medicare health plan that you choose affects many things like cost, benefits, doctor choice, convenience, and quality.
Updated: 02/21/07
What is Medigap?
A Medigap policy is a health insurance policy sold by private insurance companies to fill the “gaps” in Medicare coverage. As modified in 1992, Medigap consisted of 10 standard benefit packages, Plans A – J, that covered patient costs such as deductibles and co-insurance amounts. In 2006, two new plans (K and L) were added to the list. As a result of the introduction of Part D, no new Medigap policies sold after January 1, 2006, can provide for prescription drug coverage. Individuals who were enrolled in Medigap plans that contained such coverage (plans H, I, and J) have the option of keeping these plans, although the drug coverage is eliminated if they opt to enroll in Part D.
Updated: 02/21/07
I have Employer or Union Group Health Insurance. Will my coverage through this plan continue once I'm eligible for Medicare?
Some employer and union-provided health insurance policies can continue to provide coverage for you when you are 65 and retired. These plans may coordinate benefits with Medicare. Contact your former employer or union for information on your plan.
Medicare has special rules that apply to group health plans that provide coverage to Medicare beneficiaries through their employer or their spouse's current employer. If the employer has 20 or more employees, the plan offered to the Medicare beneficiary must be the same health insurance coverage that younger workers and spouses receive.
Updated: 02/21/07
Will my retiree-or employer-sponsored insurance cover my Medicare 20 percent Part B co-insurance?
Not always. The level of benefits and coverage of the employer-sponsored plans vary. Retiree or employer-sponsored secondary plans may vary from the 12 standardized Medigap plans in terms of what they cover and reimburse. In some cases, an employer-sponsored plan may provide healthcare coverage above what Medicare provides. Check with your former employer or union for more information to verify how they will work with Medicare to coordinate your healthcare benefits.
Updated: 12/10/07
What are Medicare prescription drug plans (PDP)?
As part of the Medicare Modernization Act (MMA), Medicare began offering comprehensive outpatient prescription drug coverage to beneficiaries in January 2006. Private insurance companies work with Medicare to offer these drug plans.
Medicare prescription drug plans provide insurance coverage for prescription drugs. Like other insurance, if you join, you will pay a monthly premium and pay a share of the cost of your prescriptions. Costs will vary depending on the drug plan that you choose.
Updated: 12/10/07
How are these drug plans different from each other?
Drug plans may vary in terms of the coverage they provide including which prescription drugs are covered, how much you have to pay, and which pharmacies you can use. Medicare has set minimum standards for prescription drug coverage that all plans must meet. Some plans might offer more coverage and additional drugs than the minimum standard, but these plans may have higher monthly premiums and other patient costs. When you join a drug plan, it is important for you to choose one that meets your prescription drug needs.
Updated: 02/21/07
When can I join a Medicare prescription drug plan? And, when does my coverage become effective?
Between November 15 and December 31 of each year, you can select a new Part D plan. The change will be effective January 1 of the following year.
Updated: 02/21/07
When will I be eligible for Medicare Part A and Part B?
You can enroll in Medicare, any Medicare Advantage Plan, or other Medicare Health Plan or Medicare Prescription Drug Plan available in your area when you first become eligible for Medicare. Eligibility begins three months before the month you turn age 65 and ends three months after the month you turn age 65. If you get Medicare due to a disability, you can join beginning three months before until three months after your 24th month of cash disability benefits.
Updated: 12/10/07
If I join a Part D plan and it does not meet my needs, can I change plans?
Yes, but when you can change and how often you can change will vary. Beneficiaries that are considered dual-eligible with both Medicare and full Medicaid may change plans at any time during the year. Other low-income beneficiaries with income less than 150% of FPL may change plans once during the year. All others including those enrolled in a standard benefit may only change plans during the annual election period which runs from November 15 - December 31 each year.
Updated: 02/21/07
How can I get help choosing a Medicare prescription drug plan?
You can get personalized information at www.medicare.gov on the web or by calling 1-800-MEDICARE (1-800-633-4227). Your State Health Insurance Assistance Program (SHIP) can provide you with free health insurance counseling. You maybe able to access assistance with enrolling in a Part D plan from a local community-based organization.
Updated: 02/21/07
What if I already have prescription drug coverage through a Medigap (supplemental insurance) policy?
If you join a Medicare prescription drug plan, you will need to contact your Medigap plan to remove the drug coverage portion of your policy, but keep your medical coverage with the Medigap plan. Once you remove the prescription drug coverage portion of your Medigap plan, you will not be able to get it back.
Updated: 02/21/07
What if I already have prescription drug coverage through an employer or union?
If your employer or union plan covers as much as or more than a Medicare prescription drug plan, you can...
- Keep your current drug plan. If you join a Medicare prescription drug plan later, your monthly premium won't be higher, or
- Drop your current drug plan and join a Medicare prescription drug plan, but you may not be able to get your employer or union drug plan back.
If your employer or union plan covers less than a Medicare prescription drug plan, you can...
- Keep your current drug plan and join a Medicare prescription drug plan to give you more complete prescription drug coverage, or
- Just keep your current drug plan. But, if you join a Medicare prescription drug plan later, you will have to pay a higher monthly premium, or
- Drop your current drug plan and join a Medicare prescription drug plan, but you may not be able to get your employer or union drug plan back.
Updated: 02/21/07
How do I know if my drugs are covered?
Medicare drug plans cover generic and brand-name drugs; however, the specific drugs covered may vary depending on the drug plan’s formulary (list of covered drugs). You can obtain the list of each plan’s covered drugs by calling the plan, visiting their website, or visiting www.medicare.gov on the web.
Updated: 02/21/07
What if I can't pay for a Medicare prescription drug plan?
Many people with limited income and assets will qualify for extra help with paying for their prescriptions. The extra help may cover the drug plan’s monthly premium and/or some of the drug co-payments or co-insurance amounts. People with the lowest incomes and fewest assets will receive the most help.
For more information on how to get extra help with prescription drug costs and how to apply, call the Social Security Administration at 1-800-772-1213 or visit www.socialsecurity.gov on the web. You can apply through the Social Security Administration or your state Medical assistance office.
Updated: 02/21/07
What do I need to do to apply for extra help with my Medicare prescription drugs?
You must apply through the Social Security Administration. If you qualify for extra help, you still need to join a Medicare prescription drug plan for Medicare to pay for your drug costs.
Updated: 02/21/07
If I have Medicaid and Medicare, what happens to my Medicaid prescription drug coverage?
Due to the implementation of the Medicare prescription drug program, as of January 1, 2006, Medicaid no longer pays for most prescription drugs. You will need to join a Medicare prescription drug plan for Medicare to pay for your drugs.
You will have to pay a small amount out of your own pocket for your prescriptions.
Updated: 02/21/07
What happens if I have SSI (Supplemental Security Income) and I'm enrolled in Medicare Savings Programs (MSPs)?
You will need to join a Medicare prescription drug plan for Medicare to pay for your drugs. For more information, look in the "Medicare & You 2009" handbook by visiting www.medicare.gov on the web or by calling 1-800-MEDICARE (1-800-633-4227).
You automatically qualify for extra help with your prescription drug costs. This means that if you join a Medicare prescription drug plan, you will pay a small amount out of your own pocket for your prescriptions.
Updated: 12/10/07
What about prescription coverage through State Pharmacy Assistance Programs (SPAPs)?
Each state determines how its SPAP will work with Medicare prescription drug coverage. Some states may choose to give extra coverage when you join a Medicare prescription drug plan. You should contact your SPAP for more information.
Updated: 02/21/07
How can I get more information about Medicare Part D?
For further information you can look in the "Medicare & You 2009" handbook, by visiting www.medicare.gov on the web or by calling 1-800-MEDICARE (1-800-633-4227). For more information on who can get extra help with prescription drug costs and how to apply, call the Social Security Administration (SSA) at 1-800-772-1213 or visit www.socialsecurity.gov on the web.
Updated: 12/10/07
Patient Costs Associated with Part D
What is considered an out-of-pocket cost under the standard Part D benefit?
Out-of-pocket costs include payments patients make toward drug costs, including deductibles and co-insurance. The monthly premium, which varies by plan, does not count towards the out-of-pocket cost threshold.
Updated: 02/21/07
What are the out-of-pocket costs for Medicare prescription drug coverage?
When you get Medicare prescription drug coverage, you pay part of the cost and Medicare pays part of the costs. You pay a monthly fee or premium for Medicare Part D prescription drug coverage. If you have Medicare Part B, the Part D premium is in addition to your monthly Part B premium. If you belong to a Medicare Advantage Plan, the monthly premium you pay to the plan may increase if you add prescription drug coverage.
Your costs will vary depending on which plan you choose. Your plan must, at a minimum, provide a standard level of coverage as shown below. Some plans offer more coverage or lower premiums.
Standard Coverage (the minimum coverage drug plans must provide)
For 2009, you will pay the following for covered drugs:
- A monthly premium (varies depending on the plan; averages $28 for 2009)
- The first $295 per year for your prescriptions (this is called your deductible)
-
After you pay the $295 deductible, here's how the costs work:
- You pay 25% of your drug costs between $296-$2,700 ($601.25), and your plan pays the other 75% of these costs, then
- You pay 100% of your drug costs between $2,701-$6,153.75 ($3,453.75), then
- You pay 5% of your drug costs (or a small co-payment) for the rest of the calendar year.
Updated: 5/19/09
What are the true out-of-pocket (TrOOP) costs for a patient enrolled in a standard benefit plan?
For a patient that is enrolled in a standard Part D benefit, the maximum annual out-of-pocket costs for prescription drug coverage is $4,350 plus 5% of any expenditures above this threshold and the cost of a monthly premium.
Medicare Part D Premiums and Out of Pocket Costs for 2009
Beneficiary pays a $295 deductible
Beneficiary pays 25% of costs between $296 and $2,700
Beneficiary pays 100% of costs between $2,701 and $6,153.75
If your annual prescription costs are over $6,153.75:
On the costs under $6,153.75, you pay as noted above (up to $4,350), on the costs over $6,153.75, you pay (a) the greater of either 5% of the prescription drugs costs or $2.40 for generic prescription drugs and (b) $6 for brand-name prescription drugs.
| Premium |
$28.00 per month (national average)*2 |
| Deductible (standard benefit) |
$295.00 |
| Patient Co-insurance (standard benefit) |
25% up to $2,700 |
| Gap in coverage (donut hole) (standard benefit) |
No coverage between $2,701 and $4,350 |
| Catastrophic coverage (above $4,350) |
Minimum Cost-sharing in Catastrophic Coverage Portion of Benefit
Generic - $2.40
Brand - $6.00
|
1 Updated Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy. CMS letter to PDP and MA-PD Plan Sponsors. p 33. April 7, 2008.
2 CMS Office of Public Affairs, Press Release, August 14, 2008
*May vary by plan
Updated: 5/19/09
When will a patient reach the "donut hole" or gap in coverage?
For beneficiaries eligible for a low-income subsidy, there is no gap in coverage. For beneficiaries enrolled in a standard benefit plan, the gap in coverage occurs once the plan and patient have incurred $2,700 in total drug spend, or $896.25 out of pocket for the patient. The actual month when the patient reaches the donut hole is dependent on the monthly drug costs of the patient.
Updated: 5/19/09
What level of assistance may I receive should I be deemed eligible for a low income subsidy?
Depending on your household income and resources the Part D cost sharing subsidy will vary.
- If you earn less than 100% of the federal poverty level (FPL), you are not subject to an asset test and are not responsible for either a premium or deductible. There is no gap in coverage for you and prescriptions will cost $1.10 for generics and $3.20 for brand-name drugs.
- If you earn more than 100% of FPL but less than 135% of FPL, are eligible for Medicaid, and have assets worth ≤ $6,290 (single) or ≤ $9,440 (couples), you are not responsible for a deductible or premium. If you are not eligible for Medicaid, you will be responsible for a $60 deductible. There is no gap in coverage for you and prescriptions will cost about $2.40 for generics and $6.00 for brand-name drugs.
- If you earn more than 135% of FPL but less than 150% of FPL and have assets worth less than $10,491 (single) or $20,971 (couple), you are responsible for a $60 deductible and a small premium (determined by income level). There is no gap in coverage for you.
Medicare Rx LIS (2009)
| Dual Eligibles |
Non-Dual Eligibles |
|
Up to 100% federal poverty level (FPL) |
Above 100% FPL Assets below
$6,291 (single)
$9,441 (couple)
|
Up to 135% FPL Assets below
$10,491 (single)
$20,971 (couple)
|
Up to 135% FPL Assets below
$10,491 (single)
$20,971 (couple)
|
Up to 135% FPL Assets below
$10,491 (single)
$20,971 (couple)
|
| No premium |
No premium |
No premium |
No premium |
Sliding scale premium subsidy (25%-75%) |
| No deductible |
No deductible |
No deductible |
$60 deductible |
$60 deductible |
| No coverage gap |
No coverage gap |
No coverage gap |
No coverage gap |
No coverage gap |
Copays:
$1.10 generic
$3.20 brand
|
Copays:
$2.40 generic
$6.00 brand
|
Copays:
$2.40 generic
$6.00 brand
|
15% coinsurance |
15% coinsurance |
| No copays if in nursing home |
No copays if in nursing home |
– |
– |
– |
Over $4,350:
No copays
|
Over $4,350:
No copays
|
Over $4,350:
No copays
|
Over $4,350:
$2.40 generic
$6.00 brand
|
Over $4,350:
$2.40 generic
$6.00 brand
|
Updated Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy. CMS letter to PDP and MA-PD Plan Sponsors. p 33. April 7, 2008.
Updated: 5/19/09
National Provider Identifier (NPI)
What is NPI?
The National Provider Identifier (NPI) uniquely identifies a health care provider in standard transactions, such as healthcare claims. NPIs may also be used to identify health care providers on prescriptions, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways.
Updated: 02/21/07
When did health care providers and health plans begin using NPI?
HIPAA requires that covered entities (i.e., health plans, healthcare clearinghouses, and those healthcare providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions by the compliance dates. The compliance date for all covered entities except small health plans was May 23, 2007; the compliance date for small health plans was May 23, 2008. As of the compliance dates, the NPI became be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.
Updated: 5/19/09
How will a health care provider obtain an NPI?
A health care provider will be able to apply for an NPI in one of three ways:
- Apply through a web-based application process. The web address is https://nppes.cms.hhs.gov.
- Prepare and send a paper application form to the Enumerator (Fox Systems). A copy of the application form, which includes the Enumerator's mailing address, can be found at https://nppes.cms.hhs.gov. A health care provider may also call the Enumerator and request a blank application form. The Enumerator's phone number is 1-800-465-3203 or TTY 1-800-692-2326.
- With the permission of the health care provider, an organization may submit a health care provider's application in an electronic file.
Updated: 02/21/07
Private Commercial Plans
What is the difference between HMO/PPO/POS/Indemnity plans?
- HMO plans typically have a limited network of providers and lower out of pocket costs for services. A primary care physician is usually selected and manages your health care and serves as a gatekeeper for referral to specialty care.
- PPO plans give economic incentives to patronize certain physicians, laboratories, and hospitals that agree to supervision and reduced fees. You may incur co-payments as well as deductibles, co-insurance, and out-of-pocket maximums for all covered services. You have flexibility to see providers both in and out of the established plan’s network; however out-of-pocket costs may be higher for out-of-network providers.
- POS plans offer the option of using “in-” or “out-of-” network providers. The patient selects a primary care physician who manages their care and is responsible for referral to plan specialists. Out-of-pocket costs are similar to those of the PPO plans.
- Indemnity plans were originally designed to provide coverage for catastrophic inpatient hospital stays and, therefore, may not cover preventative and various other services. Covered services may be subject to deductibles, co-insurance, out-of-pocket and lifetime maximums.
| Indemnity |
Preferred Provider Organization (PPO) |
Point of Service (POS) |
Health Maintenance Organization (HMO) |
- Unrestricted provider network
- Members may be responsible for difference between provider's charges and plan payment
- Members typically incur a deductible, co-insurance amounts, and out-of-pocket (stop-loss) limits
|
- Members may seek medical care within or outside plan's network of providers
- In-network services generally subject to a minimal out-of-pocket responsibility
- Out-of-network services usually incur higher out-of-pocket costs (deductibles and co-insurance)
|
- Member selects PCP from participating physician network
- When accessing care through PCP, member pays minimal out-of-pocket costs
- Subscriber can directly access care outside of the POS network at higher out-of-pocket costs
|
- Member selects a PCP and must see providers within the network
- Members typically incur low out-of-pocket costs, with minimal premiums, deductible, and co-pays
|
Updated: 5/19/09
Which of these private commercial plans is better?
This is a decision that you will have to make. Different plans can be better for different people. You may want to talk to your human resources department or plan administrator to make this decision. Your doctor’s office can even confirm if they are participating or in-network with your plan.
Updated: 02/21/07
If I change insurance plans, will my new plan cover REMICADE?
Your new plan may or may not have coverage for REMICADE. A call can be made to your new insurance plan to determine how they will cover infusions with REMICADE for you. Once you have elected your new plan, AccessOne® can provide assistance by placing this call to your insurance company and verifying how they will cover REMICADE and what your out-of-pocket costs will be.
Updated: 02/21/07
I am eligible for secondary coverage through my spouse. Should I elect this coverage?
You will need to evaluate several factors when deciding to elect secondary coverage. Some factors you may want to consider are the cost of premiums, covered benefits, and the coordination of benefits.
Updated: 02/21/07
What is meant by coordination of benefits?
Coordination of benefits is how your primary and secondary (and tertiary when applicable) insurance plans work together to pay your claims. This prevents double payment by making one insurer the primary payer and assuring that not more than 100% of the cost is covered.
Updated: 02/21/07
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