To our Patients on Medicare, welcome to ProngerSmith MedicalCare.
At the end of this article there are several phone numbers and the official Medicare website that you will find helpful.
In an effort to assist our patients in maximizing the benefits to which they are entitled from Medicare, we have created Pronger Smith MedicalCare’s, “Guide to Medicare Benefits.” This guide is designed to assist you in understanding what services Medicare will pay for and how to access these healthcare services at Pronger Smith MedicalCare. Medicare’s rule and regulations change frequently so please visit their official website for the most up to the minute details at www.medicare.gov
We are committed to providing the highest quality healthcare for you and your family. What Medicare will pay, and not pay, is often a source of great confusion to both patients and physician practices. Our primary concern is to always provide you with the best care possible.
Our Medicare Financial Policy
As a service to our patients on Medicare, Pronger Smith MedicalCare made the decision to list all our physicians as participating in the Medicare program. As a result, we will bill Medicare for all charges. As a general rule, Medicare will pay 80% of the allowed amount directly to the provider. As a courtesy to you, we will also bill all Medicare supplemental plans. We accept assignment for the services provided to patients, which means that on covered services after your deductible is met, you are only responsible for the 20% not paid by Medicare. Many supplemental plans pay the deductible and 20%.
The patient is responsible for the 20% copayment in addition to any deductibles not met. You will be responsible for any remaining balance after Medicare and the supplemental plan have paid. A statement will be mailed at that time indicating the amount due which may be paid by cash, check, Visa, MasterCard, or Discover Card. Please visit our Pay Bill on Line section. A copy of your Medicare and supplemental insurance cards are required at the time of your visit.
Medicare will not pay for some services. There are several services, which may have health benefits, but are exempt from Medicare coverage. We will attempt to identify these non-covered services in this packet, but it is your responsibility to check coverage. To assist in finding answers to coverage questions, we have included additional resources (phone numbers and web sites) in this packet.
If you are unsure whether Medicare covers a diagnosis or procedure, our billing office is available to assist you. Call (708) 388-5500 or (708) 226-7000 and select the menu option for your Medicare Patient Account Rep.
What Services Are Covered under Medicare?
Medicare has four Parts (Part A, Part B, Part C and Part D):
Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care.
Medicare Part B (Medical Insurance) (For the Doctors Office) helps cover physician services, outpatient hospital physician care and some services provided by physical and occupational therapists, and home health care. The premiums can change from year to year. Some covered services are:
- Medical and Other Services: Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, X-rays and ultrasounds, ambulatory surgery center facility fees for approved procedures, and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. Also covered is outpatient mental health care, outpatient physical and occupational therapy, including speech-language therapy.
- Clinical Laboratory Services performed in the doctor’s office: Blood tests, urinalysis, etc.
- Home Health Care: Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) and medical supplies and other services.
- Outpatient Hospital Services: Hospital services and supplies received as an outpatient as part of a doctor’s care.
- Blood: Pints of blood you get as an outpatient or as part of a Part B covered service. Medicare does not pay for the first three pints of blood.
Medicare Part C (Medicare Advantage Plan)
Medicare partnering with insurance companies developed new products known as Medicare Advantage Plans. These plans are designed to replace your original Medicare Part A and B. When seeing your physician or going to the hospital please remember to present your Medicare Advantage card and not your original Medicare card when seeing your physician. This will ensure proper billing.
Medicare Advantage plans consist of three different types of products – HMO (Health Maintenance Organization), PPO (Preferred Provider Organization) and PFFS (Paid Fee For Service).
HMO products require that you select a primary physician who will direct all your care. Pronger Smith does not accept Medicare Advantage HMO plans. Therefore if you seek services at our site you will not be covered.
PPO products allow you to seek services from in network and out of network providers. Co-payment ‘s and co-insurance is usually associated with these services and when seeing a provider that is not in network your benefits will be reduced. Pronger Smith is not part of any Medicare Advantage PPO networks. Any services obtained by us will be reimbursed at the out of network rate.
PFFS products allow you to see any Medicare provider. This product will reimburse physicians and hospitals at the Medicare rate. Just like the PPO there may be co payments or co insurance tied to some services. Please check your benefits before you seek any service. Pronger Smith does accept Medicare Advantage PFFS.
Medicare Part D (Medicare Prescription Drug Plan)
In June of 2006 Medicare required that all seniors participate in the Medicare Part D plans. These plans were designed to help seniors and Medicare disabled beneficiaries with the high cost of drugs.
The standard plan usually starts with a deductible that changes each year. During this period you are responsible for 100% of the cost of the drugs. After your deductible has been reached you are in the initial coverage portion of your coverage. During this part of the coverage your insurance company will pay 75% of the cost of the drug and you will be responsible for the difference. Generic drugs sometimes during this period will be even lower.
The next part of the coverage is known as the “donut hole” or “gap”. During this period you will be responsible for the entire cost of the drug. Some plans actually cover preferred generics in the gap. You will need to check with your insurance company to see if this is part of your plan. You remain in this period until you satisfy the total out of pocket expenses required. Each year this number changes. You can check the Medicare website to see what the totals are for this year.
When you reach the end of the “gap” you are now in the catastrophic part of your insurance. Your insurance will pay an average of 95% of the cost of the drug. You will be responsible for the difference.
If you need extra help with the cost of the drugs or premiums Social Security and your local state have programs in place to help you. You can contact you Social Security office or go to their website at www.ssa.gov to locate this extra help.
Medicare Also Helps Cover:
- Ambulance services (when other transportation would endanger your health)
- Artificial eyes
- Artificial limbs that are prosthetic devices, and their replacement parts
- Braces - arm, leg, back, and neck
- Chiropractic services (limited) for manipulation of the spine to correct a subluxation
- Emergency care.
- Eyeglasses - one pair of standard frames after cataract surgery with an intraocular lens.
- Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare).
- Kidney dialysis
- Macular eye degeneration (age- related) treatment
- Medical nutrition therapy services for people with diabetes or kidney disease with a doctor’s referral.
- Medical supplies - items such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies.
- Preventive services such as Mammograms, PSA testing and Pap Smears
- Prosthetic devices, including breast prosthesis after mastectomy
- Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners
- Therapeutic shoes for people with diabetes (in some cases)
- Transplants - heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions when performed at approved facilities)
- X-rays, MRIs, CAT scans, EKGs, and some other diagnostic tests
What is not paid for by Original Medicare Part A and Part B?
- Deductibles, coinsurance, or co-payments when you get health care services
- Dental care and dentures (in most cases)
- Cosmetic surgery
- Custodial care (help bathing, dressing, using the bathroom and eating) at home or in a nursing home
- Healthcare while traveling outside of the US (except in limited cases)
- Hearing aids and hearing exams
- Orthopedic shoes
- Routine foot care (with only a few exceptions)
- Routine eye care and most eyeglasses (see exception above for one pair of standard frames after cataract surgery with an intraocular lens)
- Routine physical exams, certain types of screen tests, some vaccinations
Preventive Medicine Services
In recent years, Medicare has expanded coverage of preventive services to encourage beneficiaries to stay healthy. Although Medicare does not pay for routine physical examinations, you’re likely to qualify for a number of important benefits– including critical preventive services, which could help prevent life- threatening illnesses. These services are designed to help you stay healthy and prevent or identify for early treatment some of the major conditions affecting older Americans.
Initial Preventive Physical Examination (IPPE)
Medicare covers an initial preventive physical examination once in a lifetime. Exam must be furnished no later than 6 months after the effective date Medicare Part B coverage begins. Beneficiary pays coinsurance and deductible.
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
An ultrasound screening for abdominal aortic aneurysm (AAA) is covered for Medicare beneficiaries with certain risk factors for abdominal aortic aneurysm. Important – Eligible beneficiaries must receive a referral for an ultrasound screening for AAA as a result of an IPPE. Beneficiary pays coinsurance, no deductible.
Cardiovascular Disease Screenings
Cardiovascular disease screening blood tests (Lipid Panel, Cholesterol, Lipoprotein, Triglycerides) are covered every 5 years for all asymptomatic Medicare beneficiaries. A 12-hour fast is required prior to testing. No coinsurance or deductible.
Bone Mass Measurements:
Medicare beneficiaries who are at risk for developing Osteoporosis are covered every 24 months, more frequently if medically necessary. Beneficiary pays coinsurance and deductible.
Colorectal Cancer Screening:
Medicare will pay for colorectal cancer screenings for all people with Medicare who are age 50 and older. Medicare covers an annual fecal occult blood test without coinsurance or deductible. A Flexible Sigmoidoscopy is covered once every four years or once every 10 years after having a screening colonoscopy. If you are at high risk for colorectal cancer Medicare covers a screening colonoscopy every 24 months or if you are not at high risk every 10 years. A barium enema instead of a sigmoidoscopy or colonoscopy is covered every 24 months at high risk or every 4 years if not at high risk. Beneficiary pays coinsurance, no deductible.
Nearly 1 of 5 people over the age of 65 has diabetes, putting them at higher risk for stroke, blindness, kidney disease and lower-limb amputations. These adverse consequences can be decreased with good diabetic management. Medicare covers insulin users and non-insulin users, as well as those whose doctor or other provider determines are at risk for complications from diabetes. Glucose monitors, test strips and lancets are covered. Beneficiary pays coinsurance and deductible.
Diabetes Self-Management Training
Diabetes self-management training is covered, up to 10 hours of initial training within a continuous 12-month period. Subsequent years: Up to 2 hours of follow-up training each year. Beneficiary pays coinsurance and deductible.
2 screening tests are allowed per year for beneficiaries diagnosed with pre-diabetes, 1 screening per year if previously tested but not diagnosed with pre-diabetes, or if never tested. No coinsurance or deductible.
Medical Nutrition Therapy
Medical nutrition therapy is covered for Medicare beneficiaries diagnosed with diabetes or a renal disease. 1st year: 3 hours of one-on-one counseling. Subsequent years: 2 hours. Beneficiary pays coinsurance and deductible.
Glaucoma screening is covered for beneficiaries in one of the high risk groups. Medicare beneficiaries with diabetes mellitus, family history of glaucoma, African-Americans age 50 and over, or Hispanic-Americans age 65 and over are covered annually. Beneficiary pays coinsurance and deductible.
Medicare covers screening mammograms for all female beneficiaries age 40 and older annually. Medicare will also cover one baseline mammogram for females ages 35-39. Beneficiary pays coinsurance, no deductible.
While Medicare pays for routine screenings only once a year, the program covers diagnostic mammograms as often as are medically necessary. For diagnostic mammograms beneficiary pays coinsurance and deductible.
Pap Smear and Pelvic Examination:
Medicare covers a pap smear, pelvic exam and clinical breast exam every 24 months. If you are a woman of childbearing age and have had an abnormal Pap smear within the preceding 36 months, or you are at high risk for cervical or vaginal cancer, Medicare will cover a Pap smear and pelvic exam every 12 months. For Exam and Pap test collection beneficiary pays coinsurance, no deductible. (No coinsurance for Pap lab test)
Prostate Cancer Screening:
Digital Rectal Exam (DRE) and Prostate Specific Antigen Test (PSA) is covered annually by Medicare for all male beneficiaries age 50 or older (coverage begins the day after 50th birthday). Digital rectal exam coinsurance and deductible apply. There is no coinsurance or deductible for the PSA test.
Flu shots are covered once per flu season in the fall or winter. No coinsurance or deductible.
Pneumonia shot is payable once in a lifetime. Medicare may provide additional vaccinations based on risk. No coinsurance or deductible. Please note that the Shingles vaccination is covered under your Medicare Part D (Drug Plan) and not under your Medicare Part B plan
Hepatitis B (HBV) is covered for Medicare beneficiaries at medium to high risk. Scheduled doses required. Eligible beneficiaries pay coinsurance and deductible.
Smoking and Tobacco-Use Cessation Counseling
Medicare beneficiaries who use tobacco and have a disease or adverse health effect linked to tobacco use or take certain therapeutic agents whose metabolism or dosage is affected by tobacco use is covered for 2 cessations attempts per year; each attempt includes maximum of 4 intermediate or intensive sessions, up to 8 sessions in a 12-month period. Eligible beneficiaries pay coinsurance and deductible. Talk to your doctor about prevention. Together, you can make sure that you are doing everything possible to stay healthy longer.
Medicare Health Care Fraud Prevention
Pronger Smith MedicalCare is committed to reducing waste, fraud and abuse in the delivery of, and reimbursement for, healthcare services. We ask our patients to join us in the effort to identify those organizations and individuals who intentionally or unintentionally add costs to our healthcare system.
Helpful websites and phone numbers
- Pronger Smith Medical Care – Blue Island Office 708-388-5500
- Pronger Smith Medical Care –Tinley Park Office 708-226-7000
- Medicare 800-633-4227 [TTY users call 877-486-2048]
- Medicare Coordination of Benefits Division 800-999-1118
- Medicare Fraud Hotline 800-447-8477
- Social Security 800-772-1213
- SHIP (Senior Health Insurance Program of Illinois) 800-548-9034
- Railroad Retirement Board 800-808-0772
- Visit www.medicare.gov