Latest news with #enrollees
Health Line
4 days ago
- General
- Health Line
What Is the Medicare Beneficiary Ombudsman?
The Medicare beneficiary ombudsman (MBO) is a representative who works on behalf of Medicare enrollees to resolve Medicare-related complaints, ensure access to information, and improve the program. An ombudsman is a person who reviews how an organization operates, investigates complaints, and helps resolve those complaints. They typically work as a client advocate within an organization or business. The MBO serves this function within the Medicare program. Learn more about the services the MBO provides and how to connect. What is the role of a Medicare beneficiary ombudsman? Congress formed the MBO role in 2003. The person in this role assists Medicare enrollees in various areas, including handling complaints, appeals, and requests for information. The general duties of the MBO, as outlined in section 1808 of the Social Security Act, are to: receive and help resolve complaints and inquiries that Medicare beneficiaries and other stakeholders make work with representatives of health insurance counseling programs to provide information and resources to beneficiaries report to Congress on ways to improve the administration of Medicare In addition to addressing complaints, some of the specific issues enrollees may have to address with an MBO include: Appeals: If you disagree with a Medicare payment or coverage determination, you can file an appeal. The MBO can assist you with this process. Enrollment concerns: If you have issues when leaving a Medicare Advantage (Part C) plan or joining a new plan, the MBO can assist you. Claims: If you need to file a Medicare claim, the MBO can help you through the process or troubleshoot issues that arise. What are a beneficiary's rights under Medicare? As a Medicare beneficiary, you have various clearly outlined rights and protections. The MBO exists to help preserve those rights and ensure fair treatment of all Medicare beneficiaries. It can be helpful for Medicare enrollees to periodically review their rights to understand what types of treatment and services they can expect. A Medicare beneficiary's rights include: fair and courteous treatment privacy of personal and health information access to appropriate healthcare professionals for medically necessary services clear, understandable information access regarding coverage, plan options, costs, and more Medicare designs its protections to keep beneficiaries up to date on coverage status and prevent unexpected costs. They come into play when Medicare may not cover a service, or you reach the end of Medicare coverage. A beneficiary's protections include: receiving an Advance Beneficiary Notice (ABN) of Noncoverage for any services that Medicare doesn't cover getting a Notice of Medicare Noncoverage at least 2 days before covered home health services end acquiring a Hospital-Issued Notice of Noncoverage (HINN) for inpatient services that Medicare Part A doesn't cover If you've experienced violations of your rights or protections or have an issue with Medicare noncoverage, you can contact the MBO for assistance. How to contact a Medicare beneficiary ombudsman Not all Medicare-related questions should go directly to the MBO. Other contact points may be more suitable based on your coverage and the nature of your question or concern. If you're a Medicare Advantage or Part D enrollee, contact your insurance carrier with any questions or complaints about your plan. You can generally find contact information for the plan on the back of your insurance card. If you have questions about Original Medicare or need help with issues that a private insurance carrier can't address, you can contact Medicare by phone at 800-633-4227. If you have general questions or would like free, unbiased Medicare counseling, you can contact your local State Health Insurance Assistance Program (SHIP). Finally, if you have questions that the channels above can't resolve, you can direct your query to the MBO. You can do so by contacting Medicare by phone at 800-633-4227 and requesting your case's submission to the MBO. Summary The MBO has a role within the Medicare program to provide customer service and advocacy. The MBO can assist Medicare beneficiaries with resolving complaints and accessing important information. They also work to improve Medicare's administration by submitting an annual report to Congress on its operation. If you have a concern requiring the MBO's attention, you can contact Medicare by phone and explain the situation.
Health Line
13-05-2025
- Health
- Health Line
Medicare Nonparticipating Providers: What You Should Know
A Medicare nonparticipating provider is a healthcare professional, facility, or supplier that doesn't accept Medicare assignment in all cases and may charge more than the Medicare-approved amount for certain services. When a healthcare professional accepts Medicare assignment, it means they agree to charge the Medicare-approved amount for all medically necessary services. Nonparticipating providers don't agree to these terms. While they still accept payment from Medicare, they may charge more for covered services. As a Medicare enrollee, receiving healthcare services from a nonparticipating provider has certain drawbacks. Learn more about what nonparticipating providers are and what to consider when getting care. Understanding Medicare assignment For Medicare billing purposes, there are three primary types of healthcare professionals: participating providers who accept Medicare assignment nonparticipating providers opt-out providers When a healthcare professional, facility, or equipment supplier 'accepts assignment,' it means they agree to charge the Medicare-approved amount for all services covered by Original Medicare (Part A and Part B). These providers can only bill Medicare enrollees for the deductible and coinsurance amounts. On the other end of the spectrum are opt-out providers. These providers don't participate in Medicare at all. If you receive services from a provider who opts out of Medicare, you must pay the full cost — except in emergencies. Nonparticipating providers are the middle ground. They may accept assignment in some cases, but they may also charge more than the Medicare-approved amount. Medicare nonparticipating providers Medicare nonparticipating providers can decide whether to accept the Medicare-approved amount for covered services on a case-by-case basis. If they don't accept the Medicare-approved amount, they can charge up to 15% more than the approved amount. This is called a limiting charge. The limiting charge amount can vary by state. In New York, it's 5%. Limiting charges may apply to services covered by Part B, but they may not apply to durable medical equipment (DME). Suppliers of DME may charge more than the limiting charge. When nonparticipating providers submit a claim to Medicare, Medicare pays them 5% less than the amount allowed under the Medicare physician fee schedule. This means nonparticipating providers get paid less than participating providers when they agree to accept assignment. At the end of each calendar year, physicians can decide whether to change their Medicare participation status or leave it as is. You can search for healthcare professionals in your area and learn whether they accept assignment using the provider search tool on Considerations when using a nonparticipating provider If you anticipate contacting a healthcare professional who is a nonparticipating provider, there are a few things to consider. Up-front payment Participating providers typically bill Medicare before asking people to pay a deductible or coinsurance amount. Nonparticipating providers may have you pay the full cost up front. Then, they submit a claim to Medicare on your behalf for any covered services. If a provider files your claim, you typically receive a Medicare summary notice that includes reimbursement for covered services or equipment. The reimbursement is 80% of the Medicare-approved amount for services covered under Part B. Limiting charges You typically pay more when receiving care from a nonparticipating provider, as these providers can charge up to 15% more than the Medicare-approved amount for covered services. Some states have rules governing how large this limiting charge may be. While a typical Medicare coinsurance is 20% of the Medicare-approved amount, if a person uses a nonparticipating provider with a 15% limiting charge, they are responsible for paying this 15% on top of their 20% coinsurance. Summary Medicare nonparticipating providers may choose to accept Medicare assignment on a case-by-case basis. This means they may charge up to 15% more than the Medicare-approved amount for covered services. The disadvantages of using a nonparticipating provider include paying higher costs for covered services, paying up front for care, and waiting for reimbursement. The downside for providers is that when they accept assignment, Medicare pays them 5% less than participating providers. You may wish to factor potential higher costs into the equation when deciding whether to get care from a nonparticipating provider.
Forbes
06-05-2025
- Health
- Forbes
Seven Things To Know About Medicare Part D And Prior Authorization
Prior authorization is becoming a bigger issue with Medicare Part D drug plans. getty Over the last several years, prior authorization has become a hot topic. Nearly all those who have Medicare Advantage plans must deal with it for medical services. You've seen the news stories about the denials and their impact on care. A new rule that will be implemented fully by 2027 is supposed to help resolve the issues but time will tell. Now, in 2025, a new wrinkle – prior authorization problems with Part D prescription drugs. Drug plans have required authorization of select medications since the program started in 2006. However, I have received several calls and emails about problems getting approval, a new phenomenon for me this year. Because of the Inflation Reduction Act and the $2,000 cap on out-of-pocket drug costs, Part D drug plans are picking up a larger share of the costs. So, they want to make sure they pay only when it is appropriate. Prior authorization is one way to ensure that. Since more enrollees seem to be dealing with this issue, here are some things to know. The top-three reasons on my list all connect to reducing the costs a plan may have to cover. There is a lower-cost alternative drug for the situation. Part A, hospital insurance, or Part B, medical insurance, should cover this drug, not the Part D plan. This drug being prescribed is not for a medically accepted indication. Part D generally doesn't cover a drug for off-label use, unless it's medically necessary, which may not be easy to prove. Other reasons for authorization can include: Drugs with special monitoring requirements Certain dosages or forms of a medication Controlled substances, and Drugs that may interact with other drugs. A man shared with me his issue with prior authorization. His 'rep' found a new plan that would save him several hundred dollars on premiums. However, now he cannot get a Tier 5 specialty drug approved. He is mad at his rep for recommending that plan. Each drug plan identifies the drugs that will be subject to authorization. It's very possible that costly Tier 4, non-preferred brand, and Tier 5 drugs will require it. After a quick check, I discovered that every plan in the man's area required authorization for his specialty medication so there was no escaping it. I have also seen many Tier 3, preferred brand, and even an occasional Tier 2, generic drug, requiring authorization. Every drug plan has its own procedure and form. Another man reported that he had been waiting almost two weeks for approval. A drug plan representative told him they could not approve the request because his physician submitted the wrong form. The insurers' forms I reviewed range from one to nine pages with some similar questions but enough variation to make using the right form important. You can find the right form by searching 'Part D prior authorization form for (name of drug plan).' Calling the plan is another option but trying to get through to the person who knows something about authorization could be difficult and time-consuming. The prescriber or the drug plan member can submit the request. I heard from a woman who ran out of her medication. When she went to get the drug on a Sunday, she was shocked to discover the new plan requires authorization. So she asked the pharmacist to do this. Pharmacists know the medications but usually are not the prescribers. The physician or healthcare practitioner who knows the rationale for a particular drug would be the best one to handle authorization. But, in a pinch, the plan member has the ability to do this with a supporting statement from the physician. The form must be completed, in its entirety, with information to support the need for the medication. When preparing the authorization form: Follow the instructions. Include a pertinent diagnosis and relevant history, symptoms, or findings. Explain why other drugs (especially less costly ones) likely won't work (could have adverse outcomes or not be as effective). The process can take time. The same woman thought the pharmacist could get authorization simply by calling the drug plan. Even if the pharmacist could connect with the right person during a weekend phone call, it's very unlikely that the plan would grant authorization. After receiving the form and supporting documentation, the plan has to notify the prescriber and enrollee withing 72 hours for a standard determination and 24 hours for an expedited one. Being proactive may help prevent some of the problems Obtaining prior authorization is generally a physician or prescriber issue. However, when able, Part D enrollees should take some responsibility to smooth out the process as much as possible. Here's a list of some things you can do. Know whether any of your drugs are subject to authorization. Find that information in the plan's documents or the Medicare Plan Finder. Do not wait until the last minute to deal with this. Discuss the situation with your physician. If possible, provide a copy of the plan's form. Watch for notification from the drug plan. Review other plans during Open Enrollment. You might find one that doesn't require authorization. But then, check the trade-offs – how this plan works and how much you might pay. Remember, of course, that determining and obtaining prior authorization when necessary is generally your provider's responsibility. But you obviously have skin in the game. So, pay attention and never hesitate to ask your provider if there's anything you can do to facilitate the process.
