Balance billing is a practice in which doctors or other health care providers bill you for charges that exceed the amount that will be reimbursed by Medicare for a particular service. If your doctor is a participating provider with Medicare, balance billing is forbidden. 93 percent of non-pediatric primary care doctors in the US are participating providers.
Some doctors aren’t participating providers with Medicare, but they also haven’t opted out of Medicare altogether. These non-participating providers can balance bill you, but the total charge can’t be more than 15 percent more than Medicare will pay the doctor. Medicare pays non-participating doctors 95 percent of the regular Medicare rate, and the doctor can increase that amount by up to 15 percent and charge it to the patient (in addition to the normal Medicare deductible and/or coinsurance that applies for the service). This 15 percent cap is known as the limiting charge.
Providers who have opted out of Medicare altogether cannot seek reimbursement from Medicare at all. The patient is fully responsible for paying the entire bill in that case, and there’s no limit to how much the provider can bill. It’s important for patients to understand the difference between a doctor who is non-participating versus a doctor who has opted out altogether, since the Medicare limiting charge doesn’t apply to doctors who have opted out of Medicare. Opting out is rare overall, but fairly common for some specialties. According to Kaiser Family Foundation data, only 1 percent of all doctors have opted out of Medicare, but that rises to 42 percent among psychiatrists.
A beneficiary, in terms of Medicare, simply refers to a person who is enrolled in Medicare. The term “Medicare enrollee” can also be used to describe a person who is enrolled in Medicare.
A beneficiary encrypted file requires your authorization before it can be read or used by health care professionals.
Your benefit period begins the very day you enter a hospital for care or a skilled nursing facility. The benefit period ends when 60 days have passed since you last received either hospital care or care from a skilled nursing facility.
The concept of a benefit period is important because the Medicare Part A deductible is based on the benefit period, rather than a calendar year.
With most other types of health insurance (ie, non-Medicare), the deductible is based on the calendar year. Once you meet it, your plan will pay all or part of your costs for the remainder of the year, but then your deductible resets on January 1. So if you happen to be hospitalized from December 30 to January 2, you’d have to pay two deductibles with most non-Medicare plans.
But with Original Medicare, that sort of scenario would be part of a single benefit period, regardless of the fact that it happens to span two calendar years, and you’d pay your Medicare Part A deductible just once.
However, you could also end up in a situation where you have two benefit periods — and have to pay your deductible twice — in the same calendar year. For example, if you’re hospitalized for a week in March, that would be the start of a benefit period. If you’re discharged and go 60 days without hospital or skilled nursing care, your benefit period would end. But then if you’re hospitalized again in October, you’d start another benefit period, and have to pay another deductible.
Families of Medicare enrollees who have passed away are entitled to bereavement services, including hospice counseling, up to a full year after the enrollee has died.