Maine Association of Retirees

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Prevent Healthcare Fraud


Medicare Minute Script

Making Sense of Your Medicare Statements

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Statements about your Medicare coverage can be confusing and difficult to read. But it is important to review these statements whenever you receive them to detect and protect yourself from Medicare fraud. They contain important information about costs and coverage of medical care and prescription drugs you have recently received. This Medicare Minute will explain how to make sense of two main types of Medicare statement: the Medicare Summary Notice (MSN) and the Explanation of Benefits (EOB).

Point 1: The type of statement you receive about your health benefits depends on your Medicare coverage.

Remember, people with Medicare have two options for receiving their Medicare health coverage: Original Medicare, the traditional Medicare program administered directly through the federal government, or a Medicare Advantage plan, a private health plan that administers Medicare benefits. If you have Original Medicare, your Medicare statement is called a Medicare Summary Notice (MSN). You generally receive your MSN in the mail on a quarterly basis. If you have a Medicare Advantage plan, you will get an Explanation of Benefits notice (EOB) on a per claim, monthly, or quarterly basis. Neither MSNs nor EOBs are bills. Rather, they detail whether Medicare or your private plan has paid for care you have received, how much they paid toward that care, and what you may owe.

Point 2: Understand the statements you receive about your Medicare Part D coverage.

In addition to an EOB or MSN that details your health coverage, you will also receive a summary statement for your Medicare prescription drug (Part D) coverage. The statements you get from your Medicare Part D plan are also called EOBs. Remember, if you have Original Medicare, you must get your Medicare Part D prescription drug coverage through a private stand-alone prescription drug plan. If you are enrolled in a Medicare Advantage plan, your Medicare Part D coverage is generally also provided through your Medicare Advantage plan. Regardless of how you get your Medicare benefits, you will get a separate Explanation of Benefits (EOB) each month about the prescription drugs you have filled. Again, this EOB is not a bill: it simply lists each prescription you have filled in the past month and indicates what you paid for medications after your plan had paid its share.

Point 3: Read your Medicare statements to keep track of what you may owe for your health and drug benefits, and to protect yourself from Medicare fraud.

Your statement will clearly mark the services received, the amount that Medicare or your plan will cover, and the maximum amount that you can be billed for the service (see the handout for an example). Your provider will send you a separate bill for any fees you owe. If you already paid your provider, make sure you paid the right amount by checking your doctor's bill against your MSN or EOB. It also helps to keep a health care journal of all the services you receive and what your doctor bills you for those services, to check against your MSN or EOB. Checking your health care journal against your statements can protect you from additional charges from your provider, and ensure that you are billed properly for services. Report any suspicious claims to your local Senior Medicare Patrol (SMP). Your statements will also list if Medicare or your plan has denied coverage for care or medications you have received. It is important to check your statements for any denials of coverage. If you see a denial, call your provider to ensure that the service was billed to Medicare correctly. If the service was billed correctly and is being denied, follow instructions to file an appeal if you disagree with the denial.


Tips For Speaking With Your Health Care Provider

Speaking with your provider is one of the best ways to understand your Medicare benefits and ensure you are receiving needed care. Here are three important items to discuss with your provider so that you have access to the best care at the lowest cost:
Point 1: Speak to your provider about which preventive care services you should receive this year.
Speaking with your provider about preventive care services can assist in the detection of dangerous illnesses.

Note: Although the preventive service itself may be free, you may be charged additional fees for certain services related to preventive care.

Point 2: Learn when Medicare will pay for a second opinion.
Medicare will pay for a second opinion if your regular provider recommends that you have surgery or a major diagnostic procedure.
Note: If you are in a Medicare Advantage Plan, different rules about second and third opinions may apply. Call your plan to find out the rules for getting second opinions.

Point 3: Know what to say to a provider who is unable or unwilling to bill Medicare.
If your Medicare provider does not think a service that is normally covered by Medicare will be covered for you, the provider should have you sign an Advance Beneficiary Notice (ABN) before providing you with the service. Before you sign the ABN, check the box that states you want your provider to submit the claim to Medicare. If you do not, your provider is not required to submit the claim.
Note: If you see an opt-out provider, the above does not apply. An opt-out provider must have you sign a form acknowledging that you will pay for their services out of pocket.
For one-on-one assistance with Medicare, contact the Maine State Health Insurance Program (SHIP) at your local Area Agency on Aging at 1-877-353-3771. For assistance with suspected billing fraud, contact the Maine Senior Medicare Patrol (SMP) at this same number.

This information is excerpted from "Medicare Minute", a publication of the Medicare Rights Center.