FAQ

Q: Why would I receive a statement for full prices for medications if I already provided my insurance to the pharmacy?

A: One of the most common mistakes we encounter is either not being supplied with prescription drug insurance at the point of admittance to the facility, or being supplied with the incorrect insurance card & info, i.e. the medical card, dental card, or Medicare Part A/B (Red, White & Blue Card) which doesn't cover prescription drugs. If we do not have this at the point of admittance, we still need to supply the medications, otherwise the facility cannot uphold their obligation to provide patient care and pass medications. So we're in a tough spot, and most commonly neither the newly admitted resident nor a power of attorney or other responsible individual is available to provide us with the necessary information. If we do not receive the information we need, a statement will be generated.


Q: If I receive a billing statement for cash transactions because the pharmacy did not have the prescription insurance at the point of admittance, can they bill the insurance retroactively?

A: Sometimes. Most insurances let us bill them retroactively 30-90 days, others longer. We will do everything we can to get you maximum value from your prescription insurance, and credit you the difference on claims we've been able to re-bill retroactively. 


Q: Why was my medication not covered by my prescription insurance?

A: Prescription insurances have formulary committees that make decisions as to what medications to cover, and what medications to not cover. There are a multitude of factors involved, including therapeutic effectiveness, cost, availability over-the-counter, availability of substantially more economical therapeutic equivalents, etc. For specific information, or to request a coverage determination from your prescription insurance, we encourage you to contact them for their specific policies, we have no access to this information.


Q: Why is my statement Past Due if I made a payment?

A: The billing date for statements is always the last day of the month. If your payment was received AFTER the billing date, that payment will not be reflected on the current statement.




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If you have any questions about you billing statement, please don't hesitate to contact our billing department.

Medicare Part A,B,C & D

A Short Description of the Various Types of Medicare.

Medicare Part A (Hospital Insurance)

Coverage for medically necessary:

  • Hospitalizations
  • Home Health
  • Skilled Nursing Care  **Note: Skilled nursing care facilities often offer both “skilled care” and “intermediate care”
  • If deemed to be in “Skilled Care,” Medicare Part A covers costs of all care, including prescription drugs.
  • If deemed to be in “Intermediate Care,” Medicare Part D covers the cost of drugs, and payment for care delivered by the nursing facility is coordinated between the resident, their family, and the facility, and there are insurances available to assist with these costs.

This coverage is free if you have worked and paid FICA taxes for at least 40 calendar quarters (10 years). If you have not worked this long and paid FICA taxes, you will pay a monthly premium for this coverage. You or your loved one will have a card that looks like the one shown below, commonly referred to the “Red, White, and Blue Card.”

Medicare Part B (Medical Insurance)

Coverage for medically necessary:

  • Physician Services
  • Outpatient services such as laboratory tests and X-rays.
  • Durable Medical Equipment including Diabetic Testing Strips, Nebulizers, Wheelchairs and some Walkers, and Oxygen and associated Supplies.
  • Some Vaccinations such as influenza and pneumococcal.
  • Some special classes of medications, including nebulized medications, anti-organ rejection medications for those who have had a kidney or liver transplant, and some cancer medications.

The benefit requirements for Medicare Part B are the same as those illustrated for Part A, and both parts share a common card, as shown above.

Medicare Part C (Medicare Advantage Plans)

• Medicare policy that allows private (commercial) health insurance companies to provide Medicare benefits.

• May be HMOs or PPOs

• Commonly referred to as Medicare Advantage plans (MA or MAPD)

• Medicare Advantage plans encompass and cover Medicare parts A, B, and D


Medicare Parts A and B will know if you or your loved one has enrolled in a Medicare Part C (Advantage Plan), and your Red, White, and Blue care will not work should you try to have a provider bill a claim for service provided to Medicare Part A or B.


Because there are multiple commercial providers of Medicare Advantage Plans, there is no universal card as in the case of Medicare Part A & B’s Red, White & Blue card. However, most plans have cards that appear as the example shown below, and will contain information for hospital providers, medical office providers, and pharmacies.

Medicare Part D (Prescription Drug Insurance)

• Provides outpatients prescription drug coverage.

• Provided only through government-contracted private insurance companies, not directly by the government. However, the government regulates these companies and dictates how they do business.

Medicare Part D (Additional Info)

As in the case of Medicare Part C plans, there are a number of Medicare Part D Plans available. Most cards appear similarly to this example card from Medco shown above, with pharmacy info only.

The Part D standard benefit, at a minimum, plan sponsors must offer a "standard benefit" package mandated by law. The standard benefit includes an annual deductible and a gap in coverage known as the "Donut Hole." Sponsors may also offer plans that differ from – but are actuarially equivalent to – the standard benefit. Finally, they may also offer "enhanced" plans that provide benefits in addition to the standard benefit. Typically, the enhanced plans offer some coverage during the Donut Hole. The Standard Benefit is defined in terms of the benefit structure, not the drugs that must be covered under the

plan.


• In 2016, the Standard Benefit includes an initial Annual Deductible of $360 (the maximum allowed under law). This is called the Deductible Phase, or Stage 1.

• After meeting the deductible the beneficiary pays 25% of the next $2,950 ($737.50) in formulary drugs. This is called the Initial Coverage Period or Stage 2.

• Once the plan and the beneficiary have together paid the Initial Coverage Limit of $3,310 the beneficiary has a gap in coverage known as the "Donut Hole," or Stage 3.

• During the Donut Hole the beneficiary pays for the next $3,752.50 in formulary drugs. On brand name drugs the member receives a 50% manufacturer discount and a 5% “subsidy” from the plan. Therefore the member’s cost will be 45%. The member’s actual 2016 cost (45%) plus the 50% manufacturer subsidy (95%), counts toward TROOP. On generic drugs the member receives a 42% subsidy from Medicare. The member’s actual out-of-pocket cost (58%) counts toward TROOP.)

• Once the beneficiary has spent a total of $4850 ($360 + $737.50 + $3752.50) in "true out-of pocket costs" (TrOOP) in formulary drugs, he/she enters the Catastrophic Coverage Period, or Stage 4.

• During Stage 4 the beneficiary pays 5% of the cost for formulary drugs, or $2.95 for generics and $7.40 for brand name drugs, whichever is greater. Beneficiaries who meet the $4,850 out-of-pocket threshold remain in Stage 4 for the rest of the calendar year. The process begins over again the next year.


Medicare does not establish premium amounts for plans. Instead, premiums are established through an annual competitive bidding process and evaluated by CMS. Medicare does establish the maximum deductible amount, the Initial Coverage Limit, the TrOOP threshold and Catastrophic Coverage levels every year. The table below shows the standard benefit each year from 2010 – 2017. This table is subject to change, and the most current version is always available at http://www.medicareadvocacy.org/medicare-info/medicare-part-d/#standard%20benefit. We’ve included this information for you convenience on our website, but recommend visiting this website for the most current information.


Due to the complexity of Medicare, the best practice is to provide all your cards to your provider, your nursing facility, and your pharmacy, and be prepared to provide them in the event of hospitalization. Make copies of them for your loved ones should they be involved in your care.

Do not be afraid to engage your plan! Medicare is your benefit, and you pay for it, or have paid for it already while part of the workforce.

If you’ve received benefits such as physician care or prescription drugs, and the provider did not have the necessary information at the point of service, you may receive an invoice for the full cost of services. These costs can usually be dealt with retroactively, however best practice is to deal with them as soon as possible!

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