Getting Reimbursed by Medicare: What You Need to Know (in Brief)

This blog post is the second in a series about Medicare that briefly outlines some of the issues surrounding Medicare payments and reimbursement. The series is geared to those folks, primarily boomers or children of older adults, who would like to know more about a subject that is becoming increasingly important to them.

While we know volumes have been written about Medicare, we strongly encourage you to speak to healthcare professionals, read extensively, and go online to the Centers for Medicare and Medicaid (CMS) website for more information, and to download, then fill out form CMS 1490S which is the Patient’s Request for Medical Payment form. If you need help, call 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048.  (A TTY – teletypewriter – is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment.)

In addition to the CMS and other government websites, you also can contact Witherell Admissions for more information at 203-618-4232 or 203-618-4314.

When should I submit a claim to Medicare for reimbursement?

Most of the time, your provider will file the claim because they have the kinds of information needed, such as type of procedure, its Medicare code, and rates. Typically, this includes Part A (hospital insurance) and Part B (medical insurance). You may get a bill later on for coinsurance or a copayment.

There are, however, times when you’ll need to either file yourself or pay for the services directly. That can happen if your provider refuses to file (perhaps they don’t take Medicare patients); or they might accept Medicare patients, but they haven’t agreed to Medicare’s rates; or if they fail to file in time – meaning within one year of the time of the procedure or services.

Can I get reimbursed for medical expenses if a medical problem occurs while I’m traveling?

Usually, Medicare doesn’t cover medical expenses incurred outside of the U.S. But there are exceptions, as, for example, if you’re on a cruise ship and the ship is still in U.S. waters (in port or within 6 hours of one) and you receive medical services; if you are traveling between Alaska and another U.S. state and receive emergency services in Canada; or if your residence is closer to a hospital outside U.S. territory. Get further information and details from the cms.gov site. 

Will Medicare pay for a travel CPAP machine?

Yes and no. Medicare has precise criteria. That said, it will only cover one device within a certain timeframe, so if you require a travel CPAP, you may need to cover these costs out-of-pocket.

Will Medicare pay for a travel wheelchair?

Medicare Part B covers a travel wheelchair if your medical condition requires it. Remember that you must receive a prescription from a licensed physician for Medicare to be aware that your travel wheelchair is a medical necessity.

Will Medicare pay for travel oxygen?

Original Medicare (Part A and Part B) will not provide oxygen coverage for your trip if you are traveling. You may rent an oxygen concentrator from a supplier.

How long does it take to receive reimbursement from Medicare?

Medicare takes approximately 30 days to process each claim. Medicare pays Part A claims (inpatient hospital care, inpatient skilled nursing facility care, skilled home health care and hospice care) directly to the facility or agency that provides the care. You are responsible for deductibles, copayments and non-covered services.

Medicare pays Part B claims (doctors’ services, outpatient hospital care, outpatient physical and speech therapy, certain home health care, ambulance services, medical supplies and equipment) either to your provider or you. This is determined by assignment. (That refers to an agreement by the health care provider to accept as payment in full the amount Medicare approves for covered services.)

If you have supplemental insurance (Medigap) and if neither Medicare nor the provider submits the claim, you will need to file the claim yourself. Fill out the claim form provided by your insurance company (if required).

• Attach copies of the bills you are submitting for payment (if required).
• Attach copies of the MSN (Medicare Summary Notice), related to those bills.
• Make copies of everything for your personal records.
• Mail your claim packet to the Medigap company or retiree plan.

What about Medicare Advantage?

Medicare Advantage plans contract with Medicare to provide your Part A and Part B benefits. Medicare pays these plans a certain monthly amount. You generally don’t need to file a claim. However, be aware that some types of Medicare Advantage plans, such as Health Maintenance Organizations (HMOs), may require you to visit the plan’s network providers. If you go to a provider outside the plan’s network, you might have to pay for the service received in full (except in medical emergencies).

How do I get reimbursed for Medicare prescription drug coverage (Part D)?                    

You need to enroll in a stand-alone Medicare Part D Prescription Drug Plan. Or, you can enroll in a Medicare Advantage Prescription Drug plan as an alternative way to get your Original Medicare (Part A and Part B) benefits, and thus get all of your Medicare coverage through a single plan. You still need to pay your monthly Medicare Part B premium, in addition to any premium the Medicare Advantage plan may charge.

If you have a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan that doesn’t cover a prescription medication your doctor prescribes, you can file an appeal. However, you might first want to speak with your doctor to see if any prescription drug your plan does cover can be substituted.

When should I file a claim?

Medicare claims must be filed no later than 12 months (or one calendar year) after the date when the services were provided. If a claim isn’t filed within this time limit, Medicare cannot pay its share.

If you have any questions about coverage, call 1-800-MEDICARE (633-4227) or TTY 1-877-486-2048.