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Medicare Reimbursement: How It Works

If you’re on Medicare, you know by now that Medicare doesn’t cover everything. You have to meet your deductibles each year, and pay your copays and coinsurance for your doctor visits. There are also some doctors who will charge more than the Medicare-approved amount for services, meaning you’ll have to pay more out-of-pocket to see them. But did you know that you can submit a claim to Medicare to receive some of your money back for some of the care that you receive? So how does Medicare reimbursement work?

Medicare Payment Process

Medicare billing works pretty similarly to that of private health insurance, except that you can see any medical provider, as long as they accept Medicare assignment. As long as they accept Medicare, your medical provider will bill Medicare, who will then pay the agreed-upon rate to the medical provider. You’ll then be left to pay the remaining out-of-pocket costs, or the coinsurance/copay.

But if you see a non-participating provider who does not agree to accept Medicare rates, they can choose to charge more than the Medicare reimbursement amount for services. Medicare allows out-of-network providers to charge up to 15% more than the approved amount for their services, also known as the limiting charge. Whatever rate they charge, you will need to pay the bill out-of-pocket and then file a claim for Medicare reimbursement.

Original Medicare

If you ever find yourself needing to pay for services upfront, you will need to file a claim with Medicare to get reimbursed. Here’s what you need to know:

The provider has 1 year to submit a bill for their services to a Medicare Administrative Contractor.
If the provider does not file within the time limit, you must complete Patient Request for Medical Payment Form 1490S.
You will have to provide itemized bills and a letter explaining why you are submitting a claim.
You will receive a Medicare Summary Notice (MSN) in the mail every 3 months, which will outline any claims for reimbursements.
Medicare Part B will reimburse 80% of the Medicare-approved amount for the healthcare services you received.

Medicare Supplement Plans

gold piggy bank — *A Medicare Supplement Plan can help you save hundreds of dollars a year on medical expenses.*

If you want to avoid having to pay for medical services out-of-pocket, you should consider a Medicare Supplement Plan. These plans work with Original Medicare to provide extra coverage for what Medicare doesn’t cover. There are 10 different types of Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Medicare Will Now Cover Aduhelm Only for Those Enrolled in Clinical Trials

Last year, there was new hope in the fight against Alzheimer’s disease when a new drug, Aduhelm, was approved for use to combat the disease. But now Medicare officials have announced their final decision to cover this drug only for people who receive it as participants in a clinical trial. This is good and bad news: while the drug won’t be as widely available, Medicare officials are considering cutting premiums for all beneficiaries, since the new drug was the reason for the $22 increase in Medicare’s Part B premiums this year.

The Price of Aduhelm

Aduhelm hit the market as the first new Alzheimer’s medication in nearly two decades, and many hoped it would be a breakthrough in fighting the disease. It was first priced at $56,000 a year, and was expected to generate billions for the company that developed it, Biogen. This astronomical price did eventually come down to $28,000 a year, but this price tag is still too high for Medicare. illustration of a green price tag in an orange circle

The high price of Aduhelm has meant that:

Doctors have been hesitant to prescribe it, given the lack of coverage and weak evidence that the drug slows the progression of Alzheimer’s.
Insurance companies have blocked or restricted coverage.
Medicare Part B premiums have gone up $22 a month, the largest increase ever.

The Future Of Aduhelm

After all the concerns from insurers, doctors, and advocacy groups, Medicare decided to restrict the new drug, and only allow coverage for it for people involved in clinical trials. Dr. Lee Fleisher, the chief medical officer at the Medicare agency, explained this decision by saying that this way of dealing with the fast-developing field of Alzheimer’s therapies, a program called Coverage with Evidence Development, “is meant to be nimble and really respond to any new drugs in this class that are in the pipeline, and do demonstrate clinical benefit.”

But Medicare is also trying to make the trials accessible to more people: instead of requiring randomized controlled trials to be approved by C.M.S., Medicare will cover participants in any trial approved by the F.D.A. or the National Institutes of Health. This will allow the trials to be done in more locations, not just in hospital settings, and to include people with other neurological conditions like Down syndrome, many of whom develop Alzheimer’s but were not included in earlier trials.

money sign in an orange circle with a blue arrow pointing down beneath it — *Officials are hoping to lower Medicare Part B Premiums since the cost of Aduhelm has gone down.*

In the trials, “the manufacturers will have to come to us with how are they going to include all patients that represent the Medicare population, and how are they going to ensure that all of these patients are getting appropriate medical treatment and monitoring of their treatment while they’re in each of these studies,” Tamara Syrek Jensen, the director of coverage and analysis for the Medicare agency’s Center for Clinical Standards and Quality, said in an interview.

Medicare Premiums

In the meantime, Medicare officials are in talks to hopefully lower Medicare Part B premiums now that they will not be covering Aduhelm for all Medicare beneficiaries, and now that the drug is coming down in price.

If you are one of the millions of Medicare beneficiaries who are living on a fixed income, saving as much money as possible is a top priority. The best way to save money on healthcare is to find an affordable Medicare Supplement Plan – and the best way to do that? Speak to an EZ agent! We work with the top-rated insurance companies in the nation and can help find a plan that will save you money this year – maybe even hundreds of dollars. Let our agents take the stress off you by comparing plans and finding ways to help you save money. And because we want to help you save as much money as possible, our services are completely free- no-obligation or hassle. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Does Medicare Cover Heart Transplants?

Heart transplants patients are getting older: 1 in 50 people who receive a heart transplant are aged 70 or older. And while heart transplants sound scary, recent studies show that survival rates continue to improve despite an increase in older and higher-risk heart transplant recipients. In fact, approximately 85 to 90% of heart transplant patients are still alive one year after their surgery, with an annual death rate of approximately 4% thereafter, and a three-year survival rate of almost 75%. This is all good news, but if you have to undergo a heart transplant, you are probably concerned about many things, including the cost of the surgery and whether Medicare will cover it.

Why Heart Transplants Become More Necessary With Age

Heart failure develops when your heart can no longer pump enough blood to provide your body with oxygen and nutrients. This can be caused by chronic conditions that you might have; if you reach heart failure, you could come to a point where medication cannot help, and the only option is to receive a heart transplant.

Medicare Coverage

One of the great things about Medicare is that it covers a wide variety of medical services, since there are different parts that cover different things. Part B covers general medical services that you would get from your doctor, and Part A covers services you receive while you’re in the hospital, as well as follow-up care and prescriptions. When it comes to receiving a transplant, Medicare Part A will pay for the surgery, as well as for finding the organ that you will receive during the surgery.

If it is not possible to receive a heart from a donor in time, you can consider receiving an artificial heart, but you should know that Medicare does not cover artificial hearts, whether permanent or temporary.

How Much Will You Pay?

Although Medicare does cover a lot of medical services and treatments, it does not cover everything 100%. Once Medicare approves the surgery, they will cover:

Services provided to prepare for the transplant, including finding the organ
The actual surgery
Follow-up services to ensure the transplant is successful
Any immunosuppressive drugs and other transplant-related prescriptions, if needed

All of the above will be covered at 100%, but you will have out-of-pocket costs, including your:

Medicare Part A deductible
Medicare Part B deductible, which must be fully paid if you receive any services following the surgery, such as rehabilitation.
Medicare Part B coinsurance- Medicare will only cover 80% of any necessary outpatient treatment and therapy sessions you receive, leaving you to pay 20% out-of-pocket

Extra Coverage

As we pointed out above, Medicare Part B will only cover the cost of services or treatment received at 80%, leaving you to pay for the other 20% out-of-pocket. If you have to have major surgery, like a heart transplant, this can be quite expensive, especially if you are living on a fixed income, as many Medicare beneficiaries are. Fortunately, though, you can save money on all your medical expenses and get extra coverage by purchasing a Medicare Supplement Plan.

There are 10 different Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost to you. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Recognizing The Early Signs of Alzheimer’s

Have you been finding yourself forgetting the small stuff lately, or maybe sometimes even forgetting the big stuff? Maybe you can’t remember where you put your keys, or what you walked into a room for – hey, it happens to the best of us! It’s normal to have bouts of forgetfulness as you age, but if it’s happening more and more often, you might be worried that what you’re experiencing is the beginning of Alzheimer’s disease. If your forgetfulness is impacting your life – for example, if you’re forgetting to pay your bills, or beginning to find things in odd places, or even if you can’t find the right words – these could be signs of dementia or Alzheimer’s. It is important to recognize the early signs of Alzheimer’s so you can seek treatment, which can help slow the progression of the disease.

Alzheimer’s Explained

Alzheimer’s is a type of dementia that affects memory, thinking, and behavior. Being forgetful is a normal part of aging, but Alzheimer’s is not. There is no cure for Alzheimer’s, and it tends to worsen over time, resulting in the loss of the ability to carry on a conversation and respond to your environment. It does eventually lead to death: it’s the 6th leading cause of death in the United States. On average, a person can live 4-8 years with Alzheimer’s, but some can live up to 20 years, especially if it is treated early.

As we said, Alzheimer’s unfortunately has no cure, but there is a new drug, Aduhelm, that has been approved to help reduce cognitive and functional decline. For this drug to be as effective as possible, it needs to be administered in the early stages of Alzheimer’s. This drug is one of the few available to treat the disease, but researchers are continuing to work on figuring out the causes of Alzheimer’s, as well as ways to treat and hopefully even prevent it.

Early Signs

As we have already stated, and cannot stress enough, treating Alzheimer’s in its early stages is the best way to help slow down its progression and give hope for a longer life. Signs to look for include:

Persistent forgetfulness– We don’t mean the regular everyday forgetfulness that most people experience once in a while, such as forgetting to take out the trash or where you put something. Persistent forgetfulness means you find yourself becoming more dependent on your phone reminding you of everyday tasks, needing to write everything down so you don’t forget, or asking the same question over and over because you don’t remember the answer.
Poor judgment– With Alzheimer’s, you will find yourself becoming more susceptible to scams or making poor choices with money because your judgment is impaired. You might even lack the judgment to know what you should wear or find yourself wearing the same thing many days in a row.
Trouble with directions– You might find yourself getting lost more often, even on routes that you normally drive or are used to. If you find yourself having trouble getting to places that you often go, it may be something to see the doctor about.
Mood swings– You might find yourself getting more easily frustrated during normal activities, or might suddenly get anxious or fearful for an unknown reason.
Withdrawing– You might not be interested in spending time with your family and friends, and might not want to participate in activities you normally would love to do. This might be because you have a hard time concentrating on what is going on, which leaves you upset, so you just choose to avoid these situations altogether
Difficulty finding the right words– We all forget a word here and there, even though it is on the tip of our tongue. But if you find this happening more often and you have a hard time following along with a conversation or finding the right words, this could be a sign of something more serious.

Get Help

If you find yourself dealing with one or more of the aforementioned early signs, it’s important to talk to your doctor. Early treatment can mean a longer and more fulfilling life, so don’t ignore the symptoms and allow the disease to progress. Medicare will cover testing, and the cost of medication, but as with all treatments, Medicare Part B will only cover 80%, leaving you to pay for the other 20% out-of-pocket. This can be quite expensive, especially if you are living on a fixed income, as many Medicare beneficiaries are. Fortunately, though, you can save money on all your medical expenses and get extra coverage by purchasing a Medicare Supplement Plan.

There are 10 different Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

How Your 2021 Tax Return Will Affect Your Future Medicare Premiums

Tax season is almost over, so as you’re getting everything squared away, you might also want to think about how your taxes will affect your Medicare premiums in the coming years. In fact, you should know that how you file your taxes this year can determine your premiums for 2023 and beyond, and if you’re married or upper-income, you might be in for some surprises. Find out exactly how your taxes this year will affect your future Medicare premiums.

Medicare Part B Premiums

When it comes to Medicare premiums, most individuals will pay the base Part B premium of $170.10 per covered person. Higher-income individuals, though, will not only pay the Part B premium, but will also pay a surcharge, or an income related monthly adjustment amount (IRMAA) on top of it.

How is this IRMAA determined? Your monthly premium depends on your modified adjusted gross income (MAGI) as reported on your 1040 form from two years ago. Your MAGI is your household’s adjusted gross income after any tax-exempt interest income and after factoring in certain tax deductions. So, that means your 2023 premiums will depend on the 2021 MAGI you reported on the 1040 form that you filed in 2021.

For 2022, an IRMAA will apply if you:

Filed individually in 2020, and reported modified adjusted gross income (MAGI) for that year in excess of $91,000.
Filed jointly for 2020 and reported MAGI for that year in excess of $182,000.

Deducting Medicare Premiums

If you’re paying a lot for your Medicare premiums, the good news is that you can write them off, as well as any other qualifying health care expenses from the year. In order to do this, you will have to itemize your deductions, and you can only include out-of-pocket medical expenses that exceed 7.5% of your adjusted gross income (AGI).

In addition, if you are self-employed, you can deduct your premiums on Schedule 1 of your 1040 form as an “above the line” deduction, which will lower your AGI. The IRS considers you to be self-employed if you own a business as either a sole proprietor (Schedule C), partner (Schedule E), limited liability company (LLC) member, or S corporation shareholder with at least 2% of company stock.

So remember: what you do with your 2021 1040 form can impact your 2023 Medicare premiums. If you do have a higher income, and are worried about what your premiums will look like in the next few years, try to itemize to get some money back, so you can hopefully offset some of your medical expenses.

Almost Done With Your Medicare “Trial Right”? Want A Different Plan? EZ Can Help

Making the switch from private health insurance to Medicare can be confusing, and even a bit anxiety-inducing. Sure, Medicare is great, but it’s not always easy to navigate if you’re not used to it. There are a lot of little things that people are unaware of when they enroll in Medicare and purchase a Medicare Supplement Plan. For example, did you know that you have a Medicare “trial right”? This right gives you the ability to test out the Medicare Supplement Plan that you’ve purchased, and if you don’t like the plan or it doesn’t work for your needs, you can switch it for another one. But remember, you only have a limited amount of time to do so!

How Long Is Your Medicare Trial Right?

calendar — *You will have 63 days to decide if you want to purchase a Medicare Supplement plan once you’ve switched to Original Medicare.*

You can technically purchase a Medicare Supplement Plan whenever you want, but if you purchase it when you first turn 65, you can avoid the underwriting process. The underwriting process is when the insurer issuing your Medicare Supplement Plan reviews your medical history; they can charge you more for your premiums or deny you coverage based on your health status.

And if you do choose to purchase a Medicare Supplement Plan or even a Medicare Advantage Plan, you have time to try out the plan, known as your trial right. For a Medicare Advantage Plan, you have a full 12 months to try out the plan, and if you think it isn’t right for you, you can switch to Original Medicare and even purchase a Medicare Supplement Plan, as well. The great thing about this trial time is that, even if you choose to switch plans, you can still bypass the underwriting process, and continue to have what is known as a guaranteed issue. You will have 63 days to decide if you want to purchase a Medicare Supplement plan once you’ve switched to Original Medicare.

Now let’s say you purchased a Medicare Supplement Plan when you enrolled in Medicare, but you feel like the plan you chose is not working for you. You will have 30 days to change your plan to a different Medicare Supplement Plan. There are 10 different plans that you can choose from that offer different coverage and premium prices.

Can You Have More Than One Trial Right Period?

Unfortunately, once you exercise your trial right to switch from Medicare Advantage to Original Medicare and a Medicare Supplement Plan, or vice versa, you will not get another chance to switch. If you want to change plans again, you will have to enroll in a Medicare Supplement Plan and go through medical underwriting. However, that does not mean you won’t still be able to find a great, affordable plan! illustration of two people talking

You can work with a Medicare agent to figure out your best option when it comes to your Medicare Supplement Plan, so you can find a plan that covers everything you need covered, and that fits in your budget.

To save as much money as you can, speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

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