Question: I recently got a Medicare Summary Notice (MSN) that indicates Medicare will not pay the bill for my test. When I contacted the provider to ask questions they said, “Medicare thinks you have other insurance.” What should I do? Do I have to pay this bill?

Answer: I do not believe you should pay this bill.

This could be one of two common reasons. First reason: you have Medicare and Medicare “thinks” you have another type of plan in front of it. Second reason you have Medicare and you signed up for Medicare Advantage Plan

I covered the first reason in last week’s article. This week I will address the second; You have Medicare A & B and you signed up for a Medicare Advantage Plan.

In this situation you already have Medicare A & B, AND you have signed up for a Medicare Advantage Plan that stands in front of Medicare A & B. Medicare will not pay for any of the services and procedures because the Medicare Advantage Plan is financially responsible for these claims. Many people who sign up for Medicare Advantage Plans don’t understand this relationship. You must have Medicare A & B, so you pay for the Part B premium ($170.10 per month for most), but Medicare is not paying your medical bills. When you sign the Contract/Enrollment Agreement with the Medicare Advantage (MA) Plan, you agreed the MA Plan will pay for your Health Care needs. This agreement requires different procedures to have claims paid. The different procedure could include, referrals for specialists, pre-approval for treatments and testing, or regional restrictions for your medical care. This is different than Medicare. Original Medicare Part A & B work anywhere in the country, no permission, no referrals required. Medicare Advantage Plans sometimes restrict your access to health care providers, or require prior approval before procedures happen.

In this situation enrollees show their Medicare Card and their Medicare Advantage Plan card. The bill may go to Medicare by mistake and Medicare will deny the claim (bill) because the MA Plan is responsible to process the claim. If the medical provider sends the claim to the correct MA Plan the claim will be processed according to their procedures and ideally paid. You may have a co-pay amount for the procedure, but the insurance company will help to pay the cost for the procedure.

If this is your situation, correcting the problem may simply require you to call your provider and talk to the billing department, to clarify that the MA Plan should be billed first and only. Medicare will not pay the claim in this situation. This could be called a Coordination of Benefits problem, but you don’t need to involve the Coordination of Benefits department of Medicare. It can usually be clarified with a quick phone call by you to your provider.

The MA Plans come in many different types, and different benefits. The types are Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), or Private Fee for Service (PFFS). Each of these plans are a replacement for Medicare. You must have Medicare A & B to enroll in the plans, but once enrolled in an MA Plan, Original Medicare A & B will not cover your medical expenses.

If you are not sure what your insurance is, take a look at your cards, you may see some of these abbreviations on the front of the card. If not, call the customer service number on the back of the card to ask about what your coverage is, or how it works. You can also call 1-800-medicare and ask what Medicare thinks you are enrolled in and that can help as well. The www.medicare.gov website is also a tool you can use, although it will not help you to track claims and bills as Medicare will not have those records. Your Medicare Advantage Plan (insurance company) will have those records. The www.medicare.gov website will indicate what insurance Medicare thinks is your primary insurance.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions, concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email at SLM@lutheran-jamestown.org.