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?

  1. 0 POINTS
    "Excess Charges" only occur with Part B coverage.
    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.
    Answered on February 3, 2015
  2. 11498 POINTS
    Jason Goldenzweig
    Co-Founder, TermInsuranceBrokers.com, Goldenzweig Financial Group, Las Vegas, Nevada
    In short, Part A is your hospital insurance and Part B is your physician insurance. Excess charges falls under what a doctor can bill you for.

    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.
    Answered on February 3, 2015
  3. 981 POINTS
    Jeffrey VanCleve
    Marketing Director, JLS Marketing Concepts LTD, Canton, OH
    Physicians do have a third option besides "Participating" or "Non-Participating". The can become a private contracting physician (opting out of Medicare), agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves. This is rare however, fewer than 1% of all physicians are private contractors. Due to limiting charges, Medicare reimbursement penalties, and administrative collection costs, Part B excess charges are an extreme rarity and not something to be concerned with. It's a non-issue in the states mentioned in a previous reply, and any Medicare beneficiary can make it a non-issue by checking that your services provider is a Participating provider in Medicare.
    Answered on March 16, 2015
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