Understanding How Medicare Billing Works

Seniors looking at documents
November 20th, 2014

Most US seniors rely on Medicare. As a caregiver, a deeper understanding of this coverage will not only help you save money by eliminating costly surprises, but it will also help you guide your loved one to an informed decision about additional health coverage.

Here’s a Look at What You Should Know about Medicare and Medicare Billing

Traditional Medicare Coverage: Parts A and B

Traditional Medicare is a public health benefit offered to seniors and some younger people with specific disabilities. It consists of two parts: Part A covers such care services as home health, skilled nursing facility, hospital, and hospice; Part B covers such preventative or medically necessary services as lab tests, ambulance services, and mental health services (among others). Part A has no monthly premium, though your loved one must still pay an annual deductible and any coinsurance on her own. Medicare Part B is an optional addition that has a monthly premium, an annual deductible, and coinsurance.

Filing a Claim

All Medicare claims are filed directly by healthcare providers; once filed, your loved one will begin to receive regular updates in the mail that show the balance owed and amount paid. Out-of-pocket costs can include coinsurance, copayments, and items that are not covered by Medicare. Coinsurance is usually a percentage of the total cost that is paid by the care recipient — this is usually about 20 percent for Medicare Part B. Copayments, on the other hand, are typically set amounts, like $20, that a senior pays per visit. These are common in hospital outpatient services, doctor’s visits, and the purchasing of prescriptions. If your loved one’s Medicare health plan or drug plan denies a request, she may be eligible to appeal.

Medicare Drug Plans: Part D

Neither Medicare Part A nor B pay for prescription medications. Instead, drug coverage is offered by optional Medicare Part D. There are a number of plans to choose from, each run by a private, Medicare-approved company. The benefits can vary widely from plan to plan, and each has its own premiums and copayments or coinsurances.

Other Coverage Options

Medicare Part C (also known as Medicare Advantage Plans) is not a separate benefit — rather, it’s the aspect of Medicare policy that enables seniors to obtain Medicare through private health insurance. This is an optional policy that takes the place of Medicare Parts A and B, and in many cases it also covers medications. Part C is a common, functionally similar alternative to traditional Medicare.

If your loved one has traditional Medicare, she may also have Medigap, or Medicare supplement insurance. These private policies pay for some of the things that aren’t covered by Medicare billing, but they require monthly premiums. While these policies can be helpful, they do not work in conjunction with Medicare Advantage Plans.

Financial Assistance

If your loved one cannot afford to pay for necessary health services or prescription drugs, there are a number of programs that may be able to help. These are known as Medicare Savings Programs (MSP). A program known as Extra Help also works with Medicare Part D. Seniors who receive Medicaid, Supplemental Security Income, or MSP aid automatically qualify, and others can apply for assistance through the program.

Understanding how Medicare billing works will allow you to help your loved one make informed choices about her healthcare and coverage. For more information and caregiver tips, visit Medicare’s extensive Caregiver Resource Kit.