|
Medicare Supplemental Insurance
Medicare Definitions
Actual Charge: The amount
a physician or supplier actually bills for a particular medical
service or supply.
Approved Amount: The amount Medicare determines to be reasonable
for a service that is covered under Part B of Medicare. It
may be less than the actual charge for physician services.
The approved amount is taken from a national fee schedule
that assigns a dollar value to all physician services covered
by Medicare.
Assignment: An arrangement
whereby a physician or medical supplier agrees to accept the
Medicare-approved amount as the total charge for services
and supplies covered under Part B. Medicare usually pays 80%
of the approved amount directly to the provider after the
beneficiary meets the annual Part B deductible of $100. The
beneficiary pays the other 20%.
Benefit Period: A benefit
period begins the first day you receive a Medicare-covered
service in a qualified hospital. It ends when you have been
out of a hospital or other facility that primarily provides
skilled nursing or rehabilitation services for 60 days in
a row. It also ends if you remain in a facility (other than
a hospital) that primarily provides skilled nursing or rehabilitation
services but does not receive any skilled care there for 60
days in a row.
Co-Insurance: The portion
or percentage of Medicare's approved amount for covered services
that beneficiary is responsible for paying.
Deductible: The amount
of expense a beneficiary must incur before Medicare begins
payment for covered services.
Excess Charge: The difference
between the Medicare approved amount for a service or supply
and the actual charge, if the actual charge is more than the
approved amount.
Limiting Charge: The
maximum amount a physician may charge for a covered service
if the physician does not accept assignment of the Medicare
claim. Limiting charge information appears on Medicare's Explanation
of Medicare Benefits (EOMB) form.
Participating Physician
& Supplier: A physician or supplier who agrees
to accept assignment on all Medicare claims.
|
