Medicare Reimbursement: When and How to Get Reimbursed
Key Takeaways
Medicare reimbursement payments are made to beneficiaries who pay Medicare’s portion of their bill out-of-pocket.
Medicare reimbursement also can refer to payments made to doctors who accept Medicare assignment and perform healthcare services.
If you have Original Medicare , you need to use a specific form when you apply for reimbursement. You also need a copy of your doctor’s bill.
If you have Medicare Advantage , you will file for reimbursement directly through your plan, not through Medicare.
If you have Part D drug coverage , you will fill out a form called a Coverage Determination Request and submit it to your Part D sponsor.
What is a Medicare Reimbursement?
If you are asked to pay more for healthcare than you are supposed to based on your Medicare coverage, you are eligible for Medicare reimbursement.
Doctors, providers and facilities also receive a form of Medicare reimbursement when they are paid by Medicare for approved services or items they provide. When you foot more of that bill than you’re supposed to based on your coverage, you are due reimbursement.
As a Medicare beneficiary, you probably see providers who accept Medicare assignment. You may have out-of-pocket costs such as copays and coinsurance you’re responsible for and expect to pay.
Occasionally, you may see a doctor or provider who doesn’t accept Medicare. Or you may go to a hospital or see a doctor who bills you for the full amount, instead of billing Medicare directly. When this happens, you can file a claim with Medicare, requesting reimbursement for that portion of your bill. Medicare reimbursement rates will depend on the details of your coverage.
Who is eligible for Medicare reimbursement?
Any Medicare beneficiary who pays their entire healthcare bill upfront, rather than only their specified portion, is entitled to Medicare reimbursement. Reimbursement may be full or partial, based upon the services received and the agreement the provider has with Medicare.
Any doctor, provider or facility that accepts Medicare assignment is eligible for Medicare reimbursement. Non-participating Medicare providers who agree to accept Medicare for specific procedures or services are also eligible for Medicare reimbursement.
While that’s true, the form of Medicare reimbursement that matters to you is the money you are due to be paid when you overpay. If that happens, here’s what you do.
Original Medicare (Part A and Part B) Reimbursement
Medicare establishes reimbursement rates for all the healthcare services and items they cover. Providers who accept Medicare agree to these fees and cannot charge patients more for them. This includes inpatient services paid for under Medicare Part A. It also includes outpatient services paid for under Medicare Part B. Part A and Part B are the two parts that comprise Original Medicare.
When you see a doctor that accepts Medicare assignment, you will be required to pay your portion of the Medicare-approved amount for the service provided.
If you see a doctor who doesn’t accept Medicare assignment, they may not file a claim with Medicare for their services. They may also charge you up to 15% more than the Medicare rate. This is known as an excess charge.
Sometimes, a hospital may fail to file a claim with Medicare. You may also receive a bill from a doctor who doesn’t accept Medicare assignment. This sometimes happens when you are a hospital inpatient. It can also happen when you receive care or testing in an emergency room setting. If you receive a bill from a doctor or hospital that you weren’t expecting, ask them if they accept Medicare assignment and if they have already billed Medicare. If they are not willing or able to submit a claim, you can file for Medicare reimbursement.
Medicare Advantage Reimbursement
Medicare Advantage (Part C) is an alternative way to get Medicare benefits. Part C plans are purchased through private insurers.
If you have a Part C plan, you don’t file for reimbursement from Medicare. Instead, you file a claim with the insurer who manages your plan. Your insurer will be able to provide you with the appropriate form you need to use. This is typically done when you see a doctor who is out of your plan’s network.
Part C plans usually have a provider network of doctors, pharmacies, suppliers and facilities. If you choose to see a doctor out of network, your out-of-pocket costs will be higher. If you pay the full amount of your bill, you can file a reimbursement claim for your plan’s portion of it directly with your insurer. Part C plans usually pay a lower amount for out-of-network physicians and suppliers than they do for those in-network.
Medicare Part D Prescription Reimbursement
Part D is prescription drug coverage you obtain through a private insurer. Part D plans have a formulary that includes the medications they cover, as well as the costs you can expect to pay for your prescriptions.
When you fill a prescription either in person or online, your pharmacist will inform you if your cost is higher than expected. They will also let you know if your provider doesn’t cover the medication you need. When a drug isn’t in your formulary, you may pay for it out-of-pocket or choose an alternative medication that your plan covers. Medications that aren’t included in a plan’s formulary are not usually reimbursed by the plan.
If you pay the full amount for a medication or vaccine that your plan covers, you can file for reimbursement. This sometimes occurs when you use an out-of-network pharmacy. It may also happen when you use an in-network pharmacy, although this is less common. In these instances, you need to file a Coverage Determination Request in order to receive Medicare reimbursement. A Coverage Determination Request refers to any decision made about your coverage by your Part D plan insurer.
Medicare Reimbursement Forms
If you have Original Medicare and wish to file for reimbursement, you need CMS Form 1490-S , the Patient’s Request for Medical Payment. This form is available in English and in Spanish.
You’ll provide information about the claim including your name, address, Medicare number, and other contact information. You’ll also need to give the exact date and place of service, your diagnosis and information about the reason why you required medical services. You will also need to submit an itemized bill from your doctor in addition to the form.
Your completed form should be mailed directly to the Medicare contractor who oversees the processing of your claims. A state list of Medicare contractors appears in the instructions section of the form. If you need more information or aren’t sure where to send your form, contact Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
For Part D reimbursements you will use a Model Coverage Determination Request Form. [i]
For Part C reimbursements, contact your health insurance company. They will point you to the appropriate form you need to use and provide instructions on how to file a claim.
