Medicare part A & part B - Deductibel and coin 2016 - Announced

The Centers for Medicare & Medicaid Services (CMS) issued the 2016 deductibles, coinsurance, and premium rates for beneficiaries covered through the Medicare fee for service program. The 2016 deductible, coinsurance and base premium rates are:

2016 Part A - Hospital insurance

Deductible: $1,288.00

Coinsurance
• $322 a day for 61st-90th day
• $644 a day for 91st-150th day (lifetime reserve days)
• $161 a day for 21st-100th day (skilled nursing facility coinsurance)


2016 Part B - Supplementary medical insurance (SMI)

Under Part B of the Medicare supplementary medical insurance (SMI) program, enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute.

Deductible: $166 a year
Coinsurance: 20 percent

Q: When is it acceptable to collect the deductible from the beneficiary?

This is the most sighted question from provider.


A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - do not collect these amounts until you receive Medicare Part B payment.

• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.)


• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.


How is the Medicare Part B annual deductible applied to payment?

A. For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.

• The deductible for 2013 and 2014 is $147.00.

Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.
If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.
Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.

• Note: Services not subject to the deductible cannot be used to satisfy the deductible.

Can provider collect Medicare deductible upfront?

Yes, we could collect the payment but it has to be refunded promptly if you are collecting excess payment or collected incorrectly. See the below what says in Medicare contract.

Yes its a good practice too improve patient payment collection.

 Provider Refunds to Beneficiaries 

In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.

Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable because of the deductible and coinsurance requirements.

Amounts are considered to have been incorrectly collected because the provider believed the beneficiary was not entitled to Medicare benefits but:

• The beneficiary was later determined to have been entitled to Medicare benefits;

• The beneficiary’s entitlement period fell within the time the provider’s agreement with CMS was in effect; and

• Such amounts exceed the beneficiary’s deductible, coinsurance or non covered services liability.



Requiring Prepayment as a Condition of Admission is Prohibited

Providers must not require advance payment of the inpatient deductible or coinsurance as a condition of admission. Additionally, providers may not require that the beneficiary prepay any Part B charges as a condition of admission, except where prepayment from  non-Medicare patients is required. In such cases, only the deductible and coinsurance may be collected.

When Prepayment May Be Requested

he provider may collect deductible or coinsurance amounts only where it appears that the patient will owe deductible or coinsurance amounts and where it is routine and
customary policy to request similar prepayment from non-Medicare patients with similar benefits that leave patients responsible for a part of the cost of their hospital services. In  admitting or registering patients, the provider must ascertain whether beneficiaries have medical insurance coverage. Where beneficiaries have medical insurance coverage, the provider asks the beneficiary if he/she has a Medicare Summary Notice (MSN) showing his/her deductible status. If a beneficiary shows that the Part B deductible is met, the provider will not request or require prepayment of the deductible.

Except in rare cases where prepayment may be required, any request for payment must be made as a request and without undue pressure. The beneficiary (and the beneficiary’s family) must not be given cause to fear that admission or treatment will be denied for failure to make the advance payment.

Providers must insure that the admitting office personnel are informed and kept fully aware of the policy on prepayment. For this purpose, and for the benefit of the provider and the public, it is desirable that a notice be posted prominently in the admitting office or lobby to the effect that no patient will be refused admission for inability to make an advance payment or deposit if Medicare is expected to pay the hospital costs.


Guide for Patient


What you pay

For most services, you (or your supplemental coverage) pay the following:

• The yearly Part B deductible if you haven’t already paid it for the year.

• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital
deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.
• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount).

The amount you pay may change each year. The amount you pay may also be different for different hospitals.

Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts.


If you paid more than the amount listed on your Medicare Summary Notice

After Medicare gets a bill from the hospital, you will get a Medicare Summary Notice. This notice will show how much you have to pay for the services you got. It will also show how much Medicare paid the hospital for the services. If the amount you paid the hospital or community mental health center at the time of service is more than what was listed on the Medicare Summary Notice, call the provider and ask for a refund. Tell them you paid more than the amount listed on the Medicare Summary Notice.

If you paid less than the amount listed on your Medicare Summary Notice

If you paid less than the amount listed on your Medicare Summary Notice, the hospital or community mental health center may bill you for the difference if you don’t have another insurer who is responsible for paying your deductible and copayments.



MEDICAID DEDUCTIBLE BENEFICIARIES AND MSP

Beneficiaries may be a MSP and also a Medicaid deductible beneficiary. The beneficiary will have a Benefit Plan ID of QMB until the deductible amount has been met. The Benefit Plan ID will change to MA once the deductible amount is met. For this Medicaid eligibility period, Medicaid reimburses the provider for Medicaid-covered services, as well as the Medicare coinsurance and deductible amounts up to the Medicaid allowable.

If Medicare covers the service, the provider may bill Medicaid for the coinsurance and deductible amounts only. For any Medicare noncovered services, the beneficiary should obtain proof of the incurred medical expense to present to the MDHHS worker so the amount may be applied toward the beneficiary's Medicaid deductible amount.

Medicare part B deductible appliing process

Deductible FAQs


Q. How is the Medicare Part B annual deductible applied to payment?

A. For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.

• The deductible for 2012, and until further notice, is $140.00.

Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.

If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.

Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.

• Note: Services not subject to the deductible cannot be used to satisfy the deductible.

Medicare Part D premium cost - patient out of pocket expense

2012 Medicare Prescription Drug Plan (part D) Premium Cost

Part D Monthly Premium


The chart below shows your estimated prescription drug plan monthly premium based on your income. If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium.


If Your Yearly Income in 2010 was

File Individual Tax Return                                  File Joint Tax Return                   You pay

$85,000 or less                                      $170,000 or less                                 Your Plan Premium

above $85,001 up to $107,000           above $170,001 up to $214,000          $11.60 + Your Plan Premium

above $107,001 up to $160,000             above $214,001 up to $320,000      $29.90 + Your Plan Premium

above $160,001 up to $214,000              above $320,001 up to $428,000     $48.10 + Your Plan Premium

above $214,000                                   above $428,000                                $66.40 + Your Plan Premium

Patient responsibility in 2012 Medicare Part B(Medical Insurance) Cost

Part B Monthly Premium


You pay a Part B premium each month. Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.


If Your Yearly Income in 2010 was

File Individual Tax Return                   File Joint Tax Return                           You pay

$85,000 or less                                    $170,000 or less                                 $99.90

above $85,001 up to $107,000            above $170,001 up to $214,000        $139.90

above $107,001 up to $160,000          above $214,001 up to $320,000        $199.80

above $160,001 up to $214,000          above $320,001 up to $428,000        $259.70

above $214,000                                   above $428,000                                $319.70



Part B Services

Services : Part B Deductible
You pay $140 per year.

Services : Blood
You pay : In most cases, the provider gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies.

If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.

Services : Clinical Laboratory Services
You pay: $0 for Medicare-approved services.

Services : Home Health Services
You pay: $0 for Medicare-approved services. You pay 20% of the Medicare-approved amount for durable medical equipment.

Services : Medical and Other Services
You pay: 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy*, and durable medical equipment.

Services : Mental Health Services
You pay: 40% of the Medicare-approved amount for most outpatient mental health care.

Services : Other Covered Services
You pay: copayment or coinsurance amounts.

Services : Outpatient Hospital Services
You pay: a coinsurance (for doctor services) or a copayment amount for most outpatient hospital services.
The copayment for a single service can't be more than the amount of the inpatient hospital deductible.

* In 2012, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits.

Note: All Medicare Advantage Plans must cover these services. Costs vary by plan and may be either higher or lower than those noted above. Review the Evidence of Coverage from your plan.

MEDICARE PREMIUMS, DEDUCTIBLES FOR 2011

Second, for most Part B beneficiaries a “hold-harmless” provision prevents their net Social Security benefit from decreasing as a result of an increase in the Part B premium. There was no increase in Social Security benefits for 2010, and, as a result of slow growth in the CPI, this result will occur again for 2011. Consequently, the increase in the Part B premium for 2011 will be paid by only a small percentage of Part B enrollees. Approximately 27 percent of beneficiaries are not protected by the hold-harmless provision because they are subject to the income-related additional premium amount (5 percent), they are new enrollees during the year (3 percent), or they do not have their Part B premiums withheld from Social Security benefit payments (19 percent, 17 percentage points of whom qualify for both Medicare and Medicaid and have their Part B premiums paid by Medicaid).

Although Part B premiums will remain flat in 2011 for the great majority of beneficiaries, program costs will still increase significantly.  In order for Part B to be adequately funded in 2011, the 2011 contingency margin has been increased to account for this situation. However, this adjustment results in a larger-than-usual premium paid by or on behalf of a minority of Part B enrollees.  No other means is available under current law to prevent a substantial decrease in account assets, which would jeopardize the ability to pay Part B benefits.

As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income.  Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2011 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.  In addition to the standard 25 percent premium, affected beneficiaries must pay an income-related monthly adjustment amount.  About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts.

The 2011 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Part B income-related monthly adjustment amount	Total monthly Part B premium amount
Less than  or equal to $85,000	Less than or equal to $170,000	$0.00	$115.40
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	$46.10	$161.50
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	$115.30	$230.70
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	$184.50	$299.90
Greater than $214,000	Greater than $428,000	$253.70	$369.10

In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at any time during the taxable year are as follows:

Beneficiaries who are married but file a separate tax return from their spouse:	Part B income-related monthly adjustment amount	Total monthly Part B premium amount
Less than or equal to $85,000	$0.00	$115.40
Greater than $85,000 and less than or equal to $129,000	$184.50	$299.90
Greater than $129,000	$253.70	$369.10

As a result of the Medicare Modernization Act, the Part B deductible was increased to $110 in 2005 and is indexed by the annual percentage increase in the Part B actuarial rate for aged beneficiaries.  In 2011, the Part B deductible will be $162.  (The actuarial rate is set by law at one-half of the total estimated per-enrollee cost of Part B benefits and administrative expenses, adjusted as necessary to maintain an adequate contingency reserve.)