Medicare B

The State of Utah, Department of Human Services, Division of Aging and Adult Services, Health Insurance Information Program, is committed to making available as much information as possible to ensure beneficiaries make informed choices about their health insurance.

The Health Insurance Information Program does not determine eligibility for, or administer any of the services mentioned in this web site.Please contact the appropriate agencies directly for your individual determination of eligibility and services.

Medicare Part B plans are administered by the federal Centers for Medicare and Medicaid Services.

Eligibility for Medicare Part B is determined by Social Security Administration.

General Information Included on this Web Page

Eligibility
Enrollment
Definitions
Beneficiary Costs
Benefits
Quality of Care
Waiver of Liability

Eligibility

Three Categories of Eligibility for Medicare Part B

Nearly everyone age 65 and over.
Disabled individuals of any age who have received 24 months of Social Security Disability benefits.
Persons of any age with end-stage renal (kidney) disease.

Role of Social Security Administration

Determines eligibility and handles enrollment.
The local Social Security office is the community resource for information and procedures surrounding eligibility and enrollment.
- The local telephone number can be found in the U.S. government listings of the telephone directory.
- The national toll free number for Social Security Administration is 1-800-772-1213.

Enrollment

Types of Enrollees

Automatically Eligible Persons:
- Those entitled to and receiving Social Security or Railroad Retirement cash benefits through early retirement are automatically entitled to Medicare Part B upon turning 65 unless they opt out of it. Also those Federal Retirees who retired after 1982 are eligible.
- Those entitled to, but not receiving, Social Security or Railroad Retirement cash benefits upon turning 65 must apply for cash benefits for Part B of Medicare to receive them.

Voluntary Enrollees:(Those who are not automatically eligible).
- Those not entitled to Social Security or Railroad Retirement cash benefits must apply for Medicare Part B upon turning 65. They can apply for Part B without applying for Part A coverage.

Enrollment Periods

Initial Enrollment

Seven-month time period surrounding the 65th birthday, (three months prior to the month of the 65th birthday, the month of the 65th birthday, and three months following the month of the 65th birthday).
The effective date for coverage during the initial enrollment period depends on the enrollment date.

If a person enrolls during the three months prior to the month the 65th birthday occurs, coverage begins on the first day of the month in which the person turns 65.
If a person enrolls during the month the 65th birthday occurs, coverage begins on the first day of the month immediately following the birthday month.
If a person enrolls during the three months following the month of the 65th birthday, coverage begins two months after enrolling when enrollment occurs in the first month following the birthday month, or coverage begins three months after enrolling when enrollment occurs in the second or third month following the birthday month.

General Enrollment

The first three months, (January, February, March), of any year following the year of the 65th birthday. Coverage will be effective July 1 of that year.
Penalties for late enrollment are imposed for enrollments that are made more than one year past the month of the person's 65th birthday.

In general, the Part B premium increases 10 percent for each 12-month period that enrollment, (effective coverage), is delayed past the seven-month initial enrollment period. There is no cap on this penalty; (e.g., a delay of five years will result in a penalty of 50 percent).

Special Enrollment

At any time while the individual is covered by an employer group health coverage plan based on his or her own , or a spouse's current employment, (not retired), OR, during the month of, or any of the seven months following the termination of, the employer group health coverage plan.
Coverage is effective the month of enrollment or any later month designated by applicant.
There is no penalty for months the individual was eligible for Medicare but did not enroll because of an employer group health plan based on current employment of self or spouse.

Definitions

Deductible
The initial amount the beneficiary is responsible for paying before Medicare coverage begins. Deductibles are determined by Medicare, the plan is administered by the Centers for Medicare and Medicaid Services.

Co-Insurance
A percentage or dollar amount of covered expense which the beneficiary is required to pay. Co-Insurance determinations are made by Medicare, the plan is administered by the Centers for Medicare and Medicaid Services.

Reasonable and Necessary Care
Part A pays only for services determined to be "reasonable and necessary" in the diagnosis or treatment of a specific illness or injury. Utilization Review Committees, Peer Review Organizations, and Intermediaries determine what care is considered reasonable and necessary. To clarify if services you are receiving are considered "reasonable and necessary", contact your physician directly.

Home Health Agency, (HHA)
A public or private agency, (non-profit or proprietary), that specializes in providing skilled nursing services and other therapeutic services, such as physical therapy, in the home.

Hospice Care
A hospice is an establishment or a program that provides for the physical and emotional needs of a terminally ill beneficiary.

Peer Review Organizations, (PROs)
Peer Review Organizations are non-governmental, physician-sponsored organizations contracted with Medicare to monitor the hospital Prospective Payment System and perform utilization and quality review functions. There is a PRO for each state. HealthInsight serves the State of Utah.

Participating Physician Agreements

The Health Care Financing Administration invites doctors to enter into "Participating Physician Agreements". Doctors who sign these agreements must accept assignment, (accept the Medicare allowable as full payment), on all claims for their Medicare patients. Doctors can "sign up" as participating providers in December of each year.
Beneficiaries can call the Medicare Offices or their doctor to find out if he or she is participating with Medicare.

Non-participating Physicians

Providers who do not sign participation agreements are called "non-participating physicians."
They do not have to accept assignment but may choose to on a claim-by-claim basis.
They have a lower Medicare Allowed Amount, and have limits on how much they can charge beyond Medicare's approved amount.

Opt Out Physician
A physician or practitioner is permitted to "Opt Out" of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements are met. The Medicare beneficiary that uses the services of an Opt Out Physician is responsible for all costs associated with the services except in the case of an emergency. For more information, contact Medicare directly.

Medicare + Choice
Congress created the Medicare + Choice program to let more private insurance companies offer coverage to people in Medicare. If you have questions regarding this program please contact Medicare directly.

Approved Charge (also called "Allowable" charge)
The amount the Part B Carrier sets for covered services and supplies upon which Part B payment is based.

Non-assigned Claims
If a physician or supplier does not agree to accept Medicare's approved charge as the total charge, it is called a non-assigned claim.

Medicare Summary Notice
After the doctor, provider, or supplier sends in a Part B claim, Medicare will send the beneficiary a notice called "Medicare Summary Notice" to tell the beneficiary the decision on the claim.

Limiting Charge

Non-participating physicians are limited to allowable caps called Limiting Charge. Non-participating suppliers are not subject to a Limiting Charge.
The most a non-participating physician can charge for a Medicare covered service in the year 2002 is 115 percent of the approved charge.
If a beneficiary's doctor has charged them over the limiting charge, (listed on their Medicare Summary Notice), they should contact their doctor and ask for a reduction in the charge, or a refund if they have paid more than the limiting charge. If they cannot resolve the issue with the doctor, they can contact Medicare Part B to ask for assistance.

Beneficiary Costs

Premium Costs
Premium Costs are determined by Medicare and administered by the Centers for Medicare and Medicaid Services .

Deductible Costs
Deductible Costs are determined by Medicare and administered by the Centers for Medicare and Medicaid Services .

Twenty Percent Co-insurance Payment

After the deductible is met, the beneficiary is responsible for 20 percent of the Medicare-approved charge. There may be more services that the beneficiary is responsible for. These costs are determined by Medicare based on particular circumstances.
Medicare pays 80 percent of the approved charges. If the provider accepts assignment, the payment will go directly to him/her. If assignment is not accepted, payment goes to the beneficiary.

Excess Charges

For non-assigned claims, the beneficiary may also be responsible for a portion of the excess charge. Excess charge is the difference between the Medicare approved charge and the provider's actual billed charge.
This excess charge is in addition to the 20 percent co-insurance payment.
In the year 2002, providers can charge no more than 115 percent of the approved charge for any service.

Services not Covered by Medicare
The beneficiary is responsible for paying for services not covered by Medicare.

Benefits

Coverage for Physician Services

For Medicare purposes, the term "physician", or "doctor", includes licensed:

Physicians, i.e., Doctors of Medicine, (M.D.), or Osteopaths, (D. O.);
Dental Surgeons, (Not all services covered by Medicare Part B);
Chiropractors, (Not all services covered by Medicare Part B);
Optometrists, (Not all services covered by Medicare Part B);
Podiatrists, (Not all services covered by Medicare Part B); and
Certain services provided by a Christian Science practitioners.

The term "physician", or "doctor", does not include Christian Science practitioners or naturopaths.
Other "qualified", reimbursable health care professionals include: Clinical psychologists and licensed clinical social workers, physician assistants, certified nurse-midwifes, nurse practitioners, and clinical nurse specialist.

Major Physician Services Covered

Medical and surgical services, (including anesthesia).
Diagnostic tests and procedures, (including X-Rays).
Services of a doctor's nurse, (incident to the physicians service).
Some drugs and biologicals administered by professionals.
Medical equipment and supplies other than common first-aid needs.
Visit to physician for second opinion about recommended surgery.
Dialysis maintenance services.

Physician's Services Which May be Covered

Clinical laboratory diagnostic services, (e.g., blood tests and urinalysis).
Outpatient treatment of mental illness.
Chiropractors' services.
Podiatrists services.

Outpatient Physical Therapy and Speech Pathology Services
Medicare Part B can help pay for medically necessary outpatient physical therapy or speech pathology services delivered in one of three ways:

As part of treatment in a physician's office.
Directly from an independently practicing, Medicare-certified physical therapist in the therapist's office, or in the home if such treatment is prescribed by a physician.
As an outpatient of a participating hospital or skilled nursing care facility, or from a home health agency, clinic, rehabilitation agency, or public health agency approved by Medicare.

Comprehensive Outpatient Rehabilitation Facilities
Covered services include:

Physician services.
Physical, speech, occupational, and respiratory therapies.
Counseling
Other related services.

Home Health Care Services

Major covered services for Home Health Care include:

Part-time skilled nursing care.
Physical therapy.
Speech therapy.
Occupational therapy.

Other covered services may be provided if the person requires at least one skilled nursing care, physical therapy, speech therapy, or occupational therapy service every 60 days. The services that Medicare B covers under these circumstances include:

Part-time services of licensed and supervised home health aides.
Medical social services.
Medical supplies and equipment provided by the agency.
Occupational therapy.

Medicare Part B covers home health care services that a home health agency provides if all of the following conditions are met:

The care needed is part-time skilled nursing care, physical therapy, or speech therapy;
The beneficiary requiring care is confined to the home;
The physician determines that the beneficiary needs home health care and sets up a plan for home health care; and
the home health agency participates in Medicare.

Ambulance Transportation

Medicare Part B covers ambulance service if:

The ambulance equipment and its personnel meet Medicare requirements; and
Transportation in any other vehicle would endanger the beneficiary's health.

Medicare covers ambulance service only to the closest facility capable of treating the patient.
Medicare covers ambulance service from the scene of an emergency or accident to a hospital, between a hospital and skilled nursing facility, or from a hospital or skilled nursing facility to the home.
There is not a limiting charge for non-assigned ambulance services. Medicare Part B covers 80 percent of the Medicare allowed charge.
If the ambulance is owned by a hospital, a beneficiary is required to pay 20 percent of the total charges.

Other Covered Services

Medicare Part B covers Portable diagnostic X-ray services.

Medicare Part B covers these services when received at home, it a physician orders them and a Medicare-certified supplier provides them.

Medicare helps pay for immunosuppressive drug therapy for three years following organ transplant. If the beneficiary is receiving drugs at a hospital pharmacy, then the intermediary processes claims.
Medicare Part B covers Federally Qualified Health Clinics, which must accept assignment.
Medicare Part B covers Mammograms

In order for Medicare to pay for a mammogram, the facility used must be Medicare certified, and have a special approval, (a certification Number), for screening mammograms.
Screening mammography is exempt from the yearly deductible.

Equipment and Supplies

For Medicare to allow coverage on a claim for equipment and/or supplies, the claim must meet the following requirements:

Be medically necessary and meet Medicare guidelines for coverage.
Be appropriate for use in your home.
Fill a medical need for you; that is, it has to be more than a convenience.
Be able to be used over and over again; in other words, it must be durable. This requirement does not apply to medical supplies.
Not be the kind of equipment that is useful to people who are not sick or injured.
Be prescribed by a doctor. However, just because your doctor prescribes an item does not guarantee it will be covered by Medicare. For example, Medicare does not cover exercise equipment, bathtub rails, shower chairs, etc. To find out if an item may be covered, or if you have any other Durable Medical Equipment Regional Carrier questions, call CIGNA toll free at 1-800-899-7095.

Medicare claims for equipment and supplies are processed by CIGNA Medicare. CIGNA is a Durable Medical Equipment Regional Carrier. CIGNA processes Medicare claims for the following items:

Durable Medical Equipment - Products that can be used over and over again. Examples include wheelchairs, walkers, hospital beds, infusion pumps, canes, etc.
Oxygen - Includes oxygen and oxygen equipment.
Prosthetics and Orthotics - Devices such as artificial limbs, breast prosthesis, glasses (after surgery), and braces may be covered. Ostomy and urological supplies are also included in this benefit.
Medical Supplies - Many medical supplies used in the home may be billed to Medicare, including surgical dressings, blood glucose strips, etc.
Parenteral and Enteral Nutrition Supplies - Under this benefit, Medicare will cover intravenous or tube feeding for patients with a permanent impairment that prevents them from eating normally.
Immunosuppressive Drugs - Immunosuppressive drugs may be covered for the benefit period after receiving a Medicare-approved organ transplant.
Home Dialysis Equipment and Supplies - Home dialysis supplies and equipment are covered when they are reasonable and necessary for patients with end stage renal disease who are being dialyzed at home under the supervision of a Medicare-approved dialysis facility.
Oral Anti-cancer Drugs - Anti-cancer medication that can be taken orally.

Medicare often identifies fraud and abuse in the area of Durable Medical Equipment. The best way to fight fraud is to make it difficult for fraudulent, unscrupulous suppliers to operate or profit.

Don't deal with medical equipment suppliers that you and your doctor don't know. Also, avoid suppliers that:

Do not have local service and maintenance offices. You'll have an easier time getting service from a local supplier and will eliminate the need for long-distance calls if you're unhappy with the equipment or service.
Use high-pressure sales tactics to sell their merchandise and who pretend to know what you need. Remember, your personal physician knows best your medical equipment needs.
Present themselves as representative of Medicare. Medicare does not solicit by telephone or mail, nor does it authorize anyone to do so. Medicare does not supply equipment, recommend specific suppliers, or provide beneficiary names to suppliers.
Send literature having Medicare emblems and symbols, leading you to believe a product or service is Medicare-approved. Medicare does not advertise or endorse particular brands, products, or companies.
Offer equipment to you at no charge. Don't be tempted by offers of free equipment. Remember, nothing is free.

Additionally, unscrupulous suppliers may:

Provide more expensive equipment than medically necessary.
Accept assignment but charge you more than 20 percent of the Medicare-approved charge.
Write medical justifications or have justifications signed by physicians who do not know you or your medical condition.
Provide lower-cost equipment while billing Medicare for higher cost equipment.
Provide used equipment while billing Medicare for new equipment.
Refuse to submit your claim to Medicare for payment.
Refuse to pick up rental items and continue to bill Medicare after you no longer need the item.
Bill Medicare for items not provided.

Help Medicare stop these unscrupulous suppliers. Always check the Medicare Summary Notice to see if the item billed to Medicare was the item you received. If you have questions, or to file a complaint, call CIGNA toll-free at 1-800-899-7095 or write to CIGNA Medicare, P.O. Box 690, Nashville, TN 37202. If you file a complaint, your name will not be used without your permission.

Quality of Care

Medicare Part B Appeals Process
In general, a Medicare Part B beneficiary may want to appeal a Medicare decision when:

Part B pays much less on a claim than he or she expected;
Part BA denies coverage for a service when coverage was expected by the beneficiary;
Mistakes occurred; or
New information is available.

If you need more information on the Appeals Process, please contact us directly at our toll free number: 1-800-541-7735

The following chart summarizes the appeals process:

Type of Action	Restrictions/Requirements
1. Reconsideration
Time Limit:	60 days
Amount:	No Minimum
Jurisdiction:	Intermediary or Peer Review Organization
Social Security Administration Form:	SSA 2649
2. Hearing, (Administrative Law Judge)
Time Limit:	60 days
Minimum Amount in Dispute:	$100 ($200 for Peer Review Organization)
Jurisdiction:	Bureau of Hearings and Appeals (BHA)
Social Security Administration Form:	HA 501.1
3. Appeals Council Review
Time Limit:	60 days
Minimum Amount in Dispute:	$100, ($200 for Peer Review Organization)
Jurisdiction:	Bureau of Hearings and Appeals (BHA)
Social Security Administration Form:	HA 520
4. Judicial Review, (Federal Court System)
Time Limit:	60 days
Minimum Amount in Dispute:	$1000, ($2000 for Peer Review Organization)
Jurisdiction:	U.S. District Court

Waiver of Liability

When Medicare payment is denied, the denial notice will tell you if you are liable for any of the denied amount.

If you have not received written notice prior to the delivery of service, you probably will be protected from payment. Do not automatically pay the provider when Medicare has denied payment. Find out who is responsible for the denied amount.

When a Medicare claim is disallowed, the beneficiary may be responsible for paying the provider for services rendered. However, in many cases, the beneficiary may have received services without knowing Medicare would not pay for them and can request that they not be held responsible for the charges.
Waiver of liability applies in situations where the beneficiary did not know, and could not have been expected to know, that services he or she received were not covered by Medicare.

Conditions for Waiver of Liability

Facility, (hospital, nursing home, or home health agency), must be Medicare certified.
Provider must have accepted assignment.
Claim has been denied on grounds that:

The service was not medically necessary
The service was not delivered in the appropriate setting
The service was not reasonable or necessary for diagnosis or treatment of illness or injury
The service was for custodial care, (in a nursing home).

Beneficiary was without fault and did not know, or reasonably could not have been expected to know, that Medicare would not cover the services. This condition is met when a provider did not give written notice to the beneficiary that Medicare would not cover the service.

Payment

If both the beneficiary and provider did not know, and could not have been expected to know, that expenses incurred were excluded from coverage, Medicare pays the provider under the waiver of liability provision.
The denial notice you receive will tell you if you have been protected from having to make payment, (liability).
If Medicare denies coverage for services, and you have already paid the provider, (and the provider knew or should have known that the service would be denied), the provider will reimburse you. If the provider will not reimburse you, contact Medicare Part A for assistance.