Medicare FAQ - 2

Second List
  1. How often will Medicare Part B pay for a mammogram? (04/01/04)
    Medicare Part B covers mammogram screening on a yearly basis for female beneficiaries age 40 or older. One screening mammography is covered for female Medicare beneficiaries between their 35th and 40th birthdays. Medicare does not cover mammogram screening for women younger than age 35. Mammogram screening is intended to detect breast cancer early, before the patient shows signs or symptoms of the disease. It's important that you talk with your health care provider to determine whether you're a candidate for screening mammography or diagnostic mammography. A diagnostic mammogram is done when there is a sign or symptom of breast disease. The Part B deductible is waived for screening mammograms.

  2. Can my provider/supplier bill me for filing claims? (01/27/05)
    Congress passed legislation that requires providers to file your Medicare Part B claims for you. They cannot, under this law, charge you for filing claims or give you completed claims to mail. If your provider doesn't file your claims, please call 1-800-MEDICARE.

  3. Will Medicare Part B cover services when I am out of the country? (04/01/04)
    In general, care provided outside of the United States (and its territories) is not covered by the Medicare Part B program. This limitation includes care provided by cruise-ship physicians. Two exceptions exist involving Canada and Mexico.

  4. Is a physician or practitioner allowed to withdraw from the Medicare Program? (04/01/04)
    Answer: Yes, but only if certain criteria are met.

    Under Section 1802 of the Social Security Act, as amended by the Balanced Budget Amendment of 1997, only certain physicians and practitioners were allowed to enter into private contracts with Medicare beneficiaries and "OPT OUT" of Medicare. With the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, §1802(b)(5)(B) of the Social Security Act, dentists, podiatrists, and optometrists were added to the definition/list of physicians who may opt out of Medicare. This went into effect on December 8, 2003. You may see a list of physicians and practitioners who have OPTED OUT of the Medicare program in Wisconsin, Illinois, Michigan, and Minnesota by

"Practitioners" permitted to opt out are physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical social workers and clinical psychologists. Physical therapists in independent practice and occupational therapists in independent practice are not allowed to "opt out" under the law's current definitions.

If a Medicare beneficiary sees one of these physicians or practitioners, the beneficiary will be asked to sign a contract, unless the visit is an emergency or urgent situation. The contract makes the patient SOLELY responsible for payment. A beneficiary may not be asked to sign a private contract if facing an emergency or urgent health situation.

  • Why is the eye refraction portion of my visit to the optometrist not covered? (04/01/04)
    Medicare pays for things that are medically necessary. Determination of the refractive state is a measurement.

  • Is it true that if you delay enrolling in Medicare that you may have to pay a penalty when enrolling at a later date? (04/01/04)
    Yes it is true. Late enrollment into Medicare will increase your premium by 10% for each year you could've been enrolled but were not.

    However, if you did not take Medicare Part B when you were first eligible because you or your spouse were working and you were covered by a group health plan or union, you can enroll at a later date without having to pay a penalty. You can sign up for Medicare Part B during a Special Enrollment Period. You can sign up:
    • Anytime you are still covered by the employer or union group health plan through your or your spouse's current or active employment, or
    • During the 8 months following the month the employer or union group health plan coverage ends, or when the employment ends (whichever is first).

    Contact Social Security Administration for more information at 1-800-772-1213 or visit

  • I receive Social Security disability benefits. When should my Medicare benefits start? (04/01/04)
    You will be automatically enrolled in Medicare after you have received your disability benefits for two years. If you have Lou Gehrig's disease (ALS), your Medicare benefits begin the first month you receive disability benefits from Social Security. For more information contact Social Security Administration at 1-800-772-1213 or visit their website at

  • Does Medicare pay for flu shots? (04/01/04)
    Yes, Medicare pays for a flu shot once every flu season. It is recommended that you received the flu shot every year in the early fall. You can get a flu shot at a doctor's office, hospitals, medical clinics or your local health department. Medicare pays 100% of the allowed amount for the flu shot. Be sure talk to your doctor about receiving a flu shot.

  • Does Medicare cover dental work? (04/01/04)
    Medicare does not cover routine dental care or procedures. This includes cleanings, fillings, teeth extractions or dentures.

  • Why does Medicare send out a Medicare Summary Notice? (04/01/04)
    Whenever Medicare processes a claim, we send you a statement or Medicare Summary Notice (MSN), to inform you of the claims we process. Your MSN contains important information. It tells you -
    • The service provided
    • Who performed it
    • Medicare's determination
    • Your financial responsibility, and
    • How to file an appeal

    Check your MSN to make sure that you received the services that Medicare paid for and report any instances of fraud to the number located in the Customer Service Information box.

  • What is an Advance Beneficiary Notice and how can it help me? (04/01/04)
    An Advance Beneficiary Notice, or ABN, is a written notice that tells you why Medicare probably (or certainly) will not pay for a service or supply and that you will be responsible for the charges. It protects you from unexpected bills. If you are presented with an ABN, you will need to make a decision whether or not to receive the service or supply. If Medicare does not pay for it, then you are responsible for the charges. You should be provided a copy of the ABN for your records.

    Read the ABN carefully. It should include -
    • A description of the service or supply
    • The reason why they believe Medicare will no pay
    • The date (must be on or before the date you receive the service or supply)

    For services that Medicare never covers, such as a routine exam, an ABN is not necessary.

  • Does Medicare cover colonoscopies? (04/01/04)
    Yes, once every 24 months if you are at high risk for colorectal cancer. If you are not at high rish for colorectal cancer, it is covered once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy.

  • What is the deductible for 2008? (12/31/07)

  • Can I pay my deductible directly to Medicare? (12/31/07)
    No. We apply your deductible to services rendered at the first of the year. You are then liable to pay your provider for those services until your deductible has been met.

  • Who decides which preventative visits are covered by Medicare? (04/01/04)
    Legislature, the Department of Health and Human Services (DHHS), and the Centers for Medicare & Medicaid Services (CMS).

  • If I miss the 7-month enrollment period, when is my next chance to enroll? Also, is there a higher premium if you enroll late? (04/01/04)
    There is an open enrollment period from 1/1 - 3/31 of every year. You will be eligible for Part B as of 7/1. Usually there is a 10% increase for each year you were not enrolled. There can be exceptions depending on the circumstances. The Social Security Administration (SSA) determines this. You can contact the SSA for more information at:

  • When I enroll in Medicare Part B, do I lock into the premium for that year or do I have to pay whatever the premium is for that year? (04/01/04)
    You do not lock in to a premium fee. You have to pay the premium price for each specific year.

  • I am no longer working (retired). Who is responsible to update my insurance record at Medicare? (04/01/04)
    It is the beneficiary's responsibility to contact the Coordination of Benefits (COB) contractor in New York at 1-800-999-1118 to have records updated. Medicare can be contacted after the COB contractor has updated the record to correct any claims processed incorrectly.

  • What does "Medically Necessary" mean? (06/18/04)
    "Medically Necessary" is defined as a service, treatment, procedure, equipment, drug, device, or supply provided by a hospital, physician, or other health care provider that is required to identify or treat a beneficiary's illness or injury, and:
    • Is proper and needed for the diagnosis, or treatment of your medical condition;
    • Is provided for the diagnosis, direct care, and treatment of your medical condition;
    • Meets the standards of good medical practice in the local area; and
    • Is not mainly for the convenience of you or your doctor.
    • Some treatments may be limited by Medicare guidelines.

  • What is the "Welcome to Medicare Physical" and can I have one? I am signed up for Medicare Part A and B. (04/28/05)
    The Medicare Modernization Act (MMA) added payment for the "Welcome to Medicare Physical Exam." If you have Medicare Part B on or after January 1, 2005, Medicare will cover a one-time preventive physical exam within the first six months that you have Part B. The "Welcome to Medicare Physical Exam" includes a measure of your height, weight, and blood pressure, an EKG, training, and guidance.

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