In this guide 5 sections
This situation can arise when a Medicare Advantage member uses a provider who accepts Medicare but has no contract with the plan and requires payment upfront. The provider's charge and the plan's reimbursement are two separate issues.
The provider cannot set any price it wants
A noncontract provider generally must accept as payment in full the amount it could collect if the patient had Original Medicare. Requiring payment upfront or refusing to bill the Medicare Advantage plan does not remove that federal limit.
The limit depends on the provider's Medicare status
- A provider that accepts assignment agrees to accept the Medicare approved amount as payment in full for covered Part A and Part B services.
- A nonparticipating provider may require full payment upfront. In many cases, the provider may charge up to 15% above the Medicare approved amount. This is called the limiting charge.
- A provider that has opted out of Medicare generally cannot receive Medicare payment, except for emergencies. Care may be provided under a private contract that makes the patient responsible for payment.
Check reimbursement before paying
- 1.Call the Medicare Advantage plan. Ask whether the provider is in network and whether the service needs prior authorization.
- 2.Ask whether the plan will reimburse a member submitted claim from this provider. Follow the claim procedure in the plan materials.
- 3.Ask the provider whether it accepts assignment, is nonparticipating, or has opted out of Medicare. Confirm the full amount it expects upfront.
- 4.Keep the itemized bill, proof of payment and supporting records. The plan may require them when reviewing the claim.
The charge limit does not guarantee reimbursement
A Medicare Advantage plan may make a separate coverage or payment decision under its rules. If the plan refuses to pay for care already received or decides that you owe more, you can appeal. The plan must provide written instructions explaining how to appeal.
Get help reviewing the bill and plan rules
- Call the plan using the number on the membership card and ask it to review the provider's status, the service and the claim procedure.
- Call Medicare at 1-800-633-4227. TTY users can call 1-877-486-2048.
- Contact the State Health Insurance Assistance Program for free, personalized Medicare counseling and help with a complaint or appeal.
- Use the Eldercare Locator or call 1-800-677-1116 to find the local Area Agency on Aging and nearby support.
Questions families ask
Can a provider charge more just because it refuses to bill my Medicare Advantage plan?
No. Refusing to bill the plan does not remove the federal payment limit for a noncontract provider. The provider generally must accept as payment in full what it could collect under Original Medicare.
Does the Medicare approved amount always equal the most I can be charged?
No. A provider that accepts assignment agrees to the Medicare approved amount. A nonparticipating provider may charge more in many cases, but the limiting charge is generally no more than 15% above the Medicare approved amount.
Will my Medicare Advantage plan reimburse everything I pay upfront?
Not necessarily. Ask the plan how its network, authorization, coverage and member submitted claim rules apply before receiving care. If the plan refuses payment for care already received, you can appeal.
What should I do if the provider says it opted out of Medicare?
Ask to review any private contract before signing or paying. Medicare generally does not pay for services from an opted out provider, except for emergencies. A State Health Insurance Assistance Program counselor can help review the situation.
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