INS. question about Medicare and Public assistance benefits?

Question

My Aunt called a Drs office to make an appt. she has Medicare as primary Ins ,and Public aid as seconday.

This office does not accept PA, so she asked if they would accept Medicare ONLY and she pay the balance. Is this legal ,what are the rules?

Answer 1

Medicare IS welfare insurance.

Most of the time, if they won't take Medicaid, they won't take Medicare, either.

Answer 2

Each medical facilty has their own policies. Usually the ones that not take medicaid also do not accept medicare.

Medicare usually pays 'reasonable and customary' rates. That means that if the medical office creates a bill for ervices of 1000.00 (for example) and medicare considers that the 'reasonable and customary' rates for services offered are only 600.00, then medicare will only pay 480.00 (only 80%). The person receiving the service will be responsible for the rest. I am not sure about Medicaid (PA), but they might also follow this 'reasonable and customary' rates policy.

This is why some people go to medigap policies, which help with this expenses.

Answer 3

The other two people who answered are wrong....Medicare is NOT welfare insurance, Medicaid is.

Yes this is entirely legal to do, people choose to do it all the time because it is hard to find a doctor who accepts Medicaid who is willing to take on any new patients.

First of all Medicare will pay as primary, she will just have to pay the yearly deductible of $135 and the coinsurance amount which is 80% of the office visit after the deductible. She might not want to do that because it is expensive and that is why she has the Medicaid (public assistance) in the first place, she has very little income and qualified for it. She will only have to pay the $135 once a year and after that a small coinsurance.

note: this deductible amount goes up a little each year though.

Medicaid is the public assistance, people who do not specialize in Medicare approved insurance plans and Medicare beneficiaries as well get the two mixed up all the time. Medicare is your Aunt's red, white, and blue card, she is entitled to this because she is either 65 or older or because she is under age 65 and has been disabled for 25 months.

Call the local Department of Family & Childrens Service and ask them if they know any doctors in your area who are accepting new patients on Medicaid. She will be better off all the way around to find a Medicaid provider, then she pays nothing out of pocket.

Best wishes to you and your aunt.