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What You Need to Know About Medicare Open Enrollment

For those who are Medicare-eligible, now through December 15th is the time to look into open enrollment options. Today we’ll look at the two main options available–Medicare Part B and Medicare Advantage plans–and weigh the differences and costs. In the past, providers only needed to participate in Medicare to see Medicare beneficiaries. With the addition of Medicare Advantage Plans, providers need contracts with several insurance companies to see patients they have already been seeing for years in order to get paid. It’s important to know what this means for your practice and your patients.

Medicare Part B

What does it cover? How is it different?

Administration

  • Medicare Part B is administered through the Social Security Administration.

Services

  • Outpatient services: annual well-patient visits, some vaccines, physical rehabilitation, etc.
  • Non-hospital medical services like physical therapy, occupational therapy, and office visits
  • Ambulance services
  • Mental health services

Equipment

  • Durable medical equipment
What are the costs?
  • Monthly premium depending on income
  • $226 deductible for ALL Medicare Part B beneficiaries in 2023
  • 20% co-insurance applies to each covered service with no maximum out of pocket
  • Physician referral may be required for payment of services
  • No-cost annual physicals, certain vaccines, and certain lab services
  • Does not cover prescription drugs (for this coverage, patient must also enroll in Medicare Part D)
  • Many patients add supplemental Medicare coverage (secondary insurance) to ease patient responsibilities, but also require additional monthly premiums
  • Medicare sets the allowable fee schedule used by many carriers

Medicare Advantage

Advantage Plans replace the patient’s Medicare Policy and add complexity to the care of patients.

What does it cover? How is it different?

Administration

  • Medicare Advantage is administered through private insurance companies abiding by Medicare coverage policies
  • Medicare Advantage plans can provide expanded coverage by combining Medicare Part A and Part B in one plan
  • May require prior authorizations for payment of service (Medicare Part B does not require prior authorizations)
  • Providers must be contracted with Advantage Plans for coverage and payment of service

Services:

  • Some plans offer additional benefits such as dental, vision, hearing, wellness benefits, and others
  • Includes prescription drug coverage
  • Limited network of contracted providers
  • Any services covered by Medicare are covered by Advantage plans
  • Advantage Plans may limit frequencies of service (physical therapy, in-network referrals, etc.)

What are the costs?

  • Monthly premium–differs based on plan options, benefits, and income
  • Deductible varies by plan
  • Co-pays and co-insurance–these vary depending on type of medical service
  • Limitations on out-of-pocket expenses–deductible, co-insurance, and copays
  • Providers bear the burden of collecting out of pocket expense–supplemental plans can not be used to pay Medicare Advantage copays, deductibles, or premiums

For the good of your patients and your practice, it’s crucial to communicate with patients and let them know who you are contracted with. Most insurance companies take many months to get providers added to networks, so don’t let your patients be left behind. You can relieve the burden of your administrative staff and ensure a satisfactory patient experience by working with PractiSynergy to handle your medical credentialing and billing.

For more information, get in touch with us today!

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