I’ve read your article (and others) about Part B excess charges, but don’t these occur elsewhere? Are there part A excess charges, or skilled nursing excess, etc. Why is only Part B excess discussed and covered with Medigap, and is a person at risk of “other” excess charges even if carrying Plan F or G supplements since those supplements don’t address “other” excess charges?
Medicare Part B Excess Charges?
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Whether or not a Medicare Beneficiary may be subjected to Part B Excess Charges by a provider depends entirely on how the provider is contracted with Medicare.
When the provider choose their method of contracting with Medicare they must choose whether they will be "Participating" or "Non-Participating".
This terminology may be confusing but it really is not.
"Participating" simply means the provider will accept the Medicare assignment of the Medicare approved amount as payment as total payment (Medicare's part) for services rendered.
"Non-Participating" means the provider has chosen to not necessarily accept the Medicare approved amount as total payment (Medicare's part) for services rendered and may choose to charge the beneficiary up to 15% of the Medicare approved amount (in addition to the beneficiary's cost sharing amount). The provider may choose on a case-by-case basis whether to seek excess charges from the beneficiary.
This rule applies ONLY to physician fee schedules thus applies only to Medicare Part B charges.
So it depends entirely upon whether the provider has chosen to contract as a "Participating" or "Non-Participating" provider with Medicare.
If you are in doubt it may be beneficial to contact the office manager at your provider's office and ask whether the provider is "Participating" or "Non-Participating" as it applies to Medicare approved payments.
All the best.
Mark
If you read an outline of coverage of a plan F or a plan G (whichever carrier's outline you want to look at doesn't matter - the plans are standardized so the input is the same regardless of company), you will see that Medicare Part A pays all but specified amounts during a hospital stay (as an inpatient) as follows:
1) First 60 days - Medicare Part A pays for all but $1,260. Medigap plan F and G pay the deductible for you.
2) Days 61-90 - Medicare Part A pays for all but $315 a day. Medigap plan F and G pay the $315 a day for you (30 days totals up to $9,450).
3) Days 91+ (while using 60 lifetime reserve days) - Medicare Part A pays for all but $630 a day. Medigap plan F and G pay the $630 a day (60 reserve days totals up to $37,800).
4) Once lifetime reserve days are used, additional 365 days - Medicare Part A pays $0. Medigap plan F and G pay 100% of Medicare-eligible expenses up to an additional 365 days.
5) Beyond the additional 365 days - Medicare Part A pays $0.
*Note - that's per benefit period! A benefit period begins on the first day you receive services as an INPATIENT and ends after you've been out of the hospital for at least 60 days in a row. It's possible to have more than one benefit period in the span of a year. Inpatient stay coverage per benefit period includes semi-private room and board, general nursing, and miscellaneous services and supplies.
Please also note, you can be in a hospital for a day or two and still be listed as an outpatient. If you're unsure, you should ask your doctor if you're listed as an inpatient or outpatient in their system.
Unless you're admitted as an inpatient, you're being treated as an outpatient which is where your Medicare Part B coverage comes into play. Part B pays about 80% of medical expenses leaving you responsible for the other 20% (covered by plans F and G). If a doctor accepts Medicare assignment, they accept the Medicare-approved amount as payment in full. If they do not accept Medicare assignment, they can bill you an excess charge - which are covered by plans F and G.
If you live in Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, you cannot be charged excess charges by a doctor due to the Medicare Overcharge Measure laws.
I hope the information is helpful - please feel free to contact me for help with your coverage and if you have any other questions. Thanks very much.