The Foreign Service Journal, December 2008

DE C EMB E R 2 0 0 8 / F OR E I GN S E R V I C E J OU R N A L 67 A F S A N E W S Retiree Issues Medicare B and FEHB Coordination: The Basics BY BONNIE BROWN, RETIREE COORDINATOR Q: I recently enrolled in Medicare B. Will Medicare reimburse my doctor for his usual charges for services? A: Thisdependsonwhether yourdoctorhas agreed toaccept theMedicare schedule of approvedamounts as payment in full for his services. Doctors fall into three categories in this regard, each with different financial consequences: First, if your doctor agrees to accept the Medicare-approved amount as payment in full — called accepting assignment — Medicare will pay 80 percent of this approved amount. You will be responsible for the other 20percent. Your doctor cannot charge you any more than the Medicare-approved amount. Second, if your doctor does not accept theMedicare-approved amount as payment in full (or does not accept assignment), but nev- ertheless treatsMedicare patients, he or she can charge up to15per- cent more than the Medicare-approved amount, and can also request full payment up front fromyou. Medicare will reimburse himor her for 80 percent of theMedicare-approved amount. You will be responsible for the other 20 percent plus whatever the doc- tor charges (up to 15 percentmore) above theMedicare-approved amount. Third, if your doctor opts out of Medicare entirely, he or she is not subject to the Medicare limits on charges and cannot submit claims to Medicare on your behalf. In this situation, your doctor will ask you to sign a private contract inwhich you affirm that you are responsible for the full cost of the services and that youwill not seek reimbursement from Medicare. If you sign this contract, Medicare will not pay for any portion of the services you receive. Q: In addition to Medicare B, I am also enrolled in a Federal Employees HealthBenefits plan. I understand that Medicare will provide primary coverage for me as a retiree. What will my FEHB plan pay as the secondary insurer? A: Read the section about coordination of benefits in your FEHB plan brochure carefully. Plans differ in their approach tocoordinatingbenefitswithMedicare; for example, some plans or options pay benefits only if you receive services fromdoc- tors who participate in their preferred-provider network. There are FEHB plans that waive the deductible and co-insur- ance amounts when doctors accept Medicare assignment. Some plans may also pay the excess costs or the additional 15 percent charged by a doctor who does not accept assignment but treats Medicare patients. If, however, your doctor has optedout ofMedicare andyouhave signeda contract agreeing tobe billed for health services, your FEHB planwill limit its payment to you to the amount it wouldhave paid after a payment byMedicare—usually 20 percent —and youwill be responsible for the balance of the charges. Q: Medicare covers an initial physical examination— a one-time “Welcome to Medicare” physical exam — within six months of enrollment, but does not cover annual physicals. Will my FEHB plan pay for my annual physicals and other non-Medicare cov- ered services? A: Again, it is important to read your FEHBplanbrochure carefully to seewhether and towhat extent your planwill pay for these services. Some plans will pay for these services and waive the deductible and coinsurance. Q: Will I have to file Medicare claims? A: Unless you signed a contract agreeing that you will not seekMedicare reimbursement, your doctor is required to file Medicare claims for the covered services you receive. In instances where doctors fail to submit a claim, youmay file a CMS 1490S form on your own behalf. The form can be found at www.cms.hhs.gov/cmsforms/downloads/cms1490s-english.pdf. If your doctor accepts assignment, he or she will file aMedicare claim for you. Medicare will then pay its share of the bill directly to the doctor and forward the claimelectronically to your FEHBplan. Even a doctor who does not acceptMedicare assignment is still required to file a Medicare claim for you. If you have paid for the services,Medicarewill pay its share of the bill directly to you. Again, if your doctor fails to submit a claim, file FormCMS 1490S. Be aware that Medicare does not electronically send complete- ly denied claims to FEHB plans. Make sure that your FEHB plan receives the documents it needs to take action: the bills for services and Medicare notices of rejection. Q. What can I do to assist in this coordination process? A: Read the section about coordination of benefits in your FEHBplanbrochure carefully. These plans—and stan- dard andbasic options offeredby the same plan—can anddodif- fer. Talk to the financial administrator in your doctor’s office about how it processes Medicare claims. Many practices do not under- stand their obligations in this regard. Readwhat you sign; signing a private contract can have serious financial consequences for you. Send a copy of your Medicare card to your FEHB plan so that it can ensure that the electronic coordination is in place for your claims. Q & A