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2007

Medicare &
You

PUBLICATION
CONTENTS:

Introduction

What Is
Medicare?

Medicare's
Gaps

Medicare
Part A Gaps

Medicare
Part B Gaps

Medicare
Part B And
Medicare
Advantage

Who Pays
First

Making A
Wise Choice

Preferred
Providers

Submitting
Claims

Prescription
Drugs

Preventive
Care

FEP BlueVision

Fraud And
Abuse

Terms And
Definitions

If You Have
Questions

Medicare Part B Assignment And The Limiting Charge

If you have both Medicare Part B and Blue Cross and Blue Shield Service Benefit Plan coverage, always ask your physician if he or she accepts Medicare assignment. If your physician accepts Medicare assignment, we will pay for most services in full up to the Medicare-approved charge, as long as Medicare is providing primary coverage. If your physician does not accept Medicare assignment, he or she may charge more than Medicare's allowance up to a limit set by Medicare called the limiting charge. We will pay for such services up to Medicare's limiting charge. Under Basic Option, the physician must also be a Preferred network provider.

What Is Medicare Assignment?

All Medicare participating providers agree to accept assignment on all claims. Non-participating Medicare providers can choose whether to accept Medicare assignment on a claim-by-claim basis.

When your doctor or supplier agrees to accept the charge approved by Medicare as total payment for services, this is called "accepting Medicare assignment." Medicare pays your doctor or supplier 80 percent of the Medicare-approved charge, after subtracting any part of the $131 annual deductible you have not met. For covered services, the doctor or supplier can charge you only for the amount applied to the deductible and the remaining 20 percent of the approved charge. This 20 percent is your coinsurance amount, which is usually paid by your Blue Cross and Blue Shield Service Benefit Plan coverage, as is the $131 Medicare annual deductible. If you want to find a physician or supplier who accepts Medicare assignment, you can also get a listing of Medicare participating providers online at www.medicare.gov.

All Providers Must File Claims For You

All physicians and other providers are required to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether they accept Medicare assignment or not and is required by law. In addition, doctors, suppliers and other providers must file Medicare Part B Claims electronically.

Please be sure your Blue Cross and Blue Shield Service Benefit Plan ID number is included on the Medicare claim form. This will help ensure that a claim for any balances remaining after Medicare's payment is forwarded to your Local Blue Cross and Blue Shield Plan for payment.

"Limiting Charge"

If Medicare is your primary coverage, in most cases your Medicare and Standard Option coverage together cover the entire approved amount for covered services. This is true for Basic Option when you use Preferred providers.

The limiting charge places a limit on how much Non-participating Medicare physicians who do not accept Medicare assignment can charge their patients.

Physicians who do not accept Medicare assignment are required by law to accept the limiting charge as payment in full. You are not responsible for any difference between the limiting charge and the physician's charge. If this happens, please contact your local Social Security or Medicare office.

If your doctor accepts Medicare assignment, the law does not affect you. Remember, participating Medicare physicians always accept 100 percent of the Medicare approved amount as payment in full.

Private Contracts

Occasionally, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by the Original Medicare. If you sign this type of agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. Our payment will be limited to the amount we would have paid after Medicare's payment. You will be responsible for paying the difference between the amount billed and the amount we pay. It's important that you're aware that private contracts can substantially increase your out-of-pocket costs.

Medicare Advantage

Under Medicare Advantage, individuals who are eligible for Medicare Parts A and B can choose to get their Medicare benefits through a variety of risk-based plans. The primary Medicare Advantage plans include:

• Medicare managed care plans, such as Health Maintenance Organizations (HMOs)

• Preferred Provider Organizations (PPOs)

• Medicare private fee-for-service plans

• Medicare Specialty plans

Your choices may be different if you have Medicaid, veteran or military benefits, or End Stage Renal Disease.

For more information about Medicare Advantage Plans contact Medicare.

If you enroll in a Medicare Advantage plan, you can also keep your Service Benefit Plan coverage. If you are an annuitant or former spouse, you can also suspend your Service Benefit Plan coverage and enroll in a Medicare Advantage plan in your area. If you want to reenroll in the Service Benefit Plan later, you may generally do so at the next Open Season. For more information, please see Section 9 of the 2007 Service Benefit Plan brochure (RI 71-005), or call OPM's Retirement Information office at 1.888.767.6738.

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