Medicare

This federal health insurance program is designed for people 65 and older, people of any age with End-Stage Renal disease or certain disabled persons under 65. Get details from the Social Security Administration at 724 20th Street, Vero Beach, 1-866-964-7414 or visit the website at www.socialsecurity.gov

There are two paths in Medicare – Original Medicare and Advantage Plans.

Part A premium-free to eligible recipients. It has a hospital deductible of $1,364 per benefit period and has a $0 co-payment for days one through sixty. A co-insurance charge schedule is applicable thereafter. In general, Part A covers hospital care, skilled nursing facility care, nursing home care (as long as custodial care isn’t the only care you need), hospice, and home health services.

If you’re in a Medicare Advantage Plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

The monthly standard Part B premium amount in 2019 is $135.50 (or higher depending on your income). However, most people who get Social Security benefits pay less than this amount. This is because the Part B premium increased more than the cost-of-living increase for 2019 Social Security benefits. If you pay your Part B premium through your monthly Social Security benefit, you’ll pay less ($109 on average). Social Security will tell you the exact amount you’ll pay for Part B in 2019. You’ll pay the standard premium amount if:

• You enroll in Part B for the first time in 2019.
• You don’t get Social Security benefits.
• You’re directly billed for your Part B premiums.
• You have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $135.50.)
• Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount. If so, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

Medicare will only always pay for medically necessary services. After reaching the annual deductible ($183), Medicare pays 80 percent, and your out-of-pocket cost is 20 percent for most covered services.

The provider who does not accept assignment may charge up to 15% more than the reduced rate (95%). The non-participating provider is permitted to bill patients for up to fifteen percent more. The patient pays the difference between the two.

EXAMPLE:

Medicare-approved amount: $100.00

Reduced rate (95%): $95.00

Excess charge (15% x $95): + $14.25

TOTAL CHARGE: $109.25

Part D is optional, but a penalty will be imposed if a beneficiary decides to enroll later in life. Part D covers prescription medications.

Fees for physician services are based on a national fee schedule. If a physician elects to accept Medicare assignment, he/she bills Medicare directly for payment. Medicare will pay the physician 80 percent of the “amount approved.” The patient is responsible for any unmet deductible and the 20 percent co-payment.

When the physician does not accept assignment, Medicare pays the doctor 80 percent of the amount approved. The non-participating doctor is permitted to bill patients for up to fifteen percent more. The patient pays the difference between the two.

www.medicare.gov
Medicare: 1-800-633-4227