For many years, the Centers for Medicare & Medicaid (CMS) has funded programs to reduce claims payment errors (either paying too much, paying too little or payments being made when none should be). Some of these programs are handled through systematic checks that look for anomalies and mismatched services, and some are handled through clinical reviews of specific claims.
The program integrity initiatives pertaining to Railroad Medicare include:
Medically Unlikely Edits (MUEs) – These are systematic checks that look for claims that exceed the maximum number of services expected to be reported, in most cases, for a single patient by the same provider on a single day.
National Correct Coding Initiative (NCCI) Edits – These are also systematic checks, and they look for combinations of codes that should not be reported together in all or most situations. Either we would not expect both services to occur in one treatment, or Medicare does not reimburse both services when performed together. This could be two codes that represent different methods of performing the same service, such as a laparoscopic gallbladder removal and an open incision gallbladder removal. It could also be two codes that are components of each other, such as a rhythm electrocardiograph (ECG) and a cardiovascular stress test, which by definition includes an ECG.
Medical Review Program – This initiative involves complex reviews by Medicare (including Railroad Medicare) in which documentation is requested, and then the reviews determine if the claim was correctly billed and properly documented, and that the services meet Medicare coverage criteria.
Comprehensive Error Rate Testing (CERT) Program – This initiative involves complex reviews in the same manner as the Medical Review program. External entities include the CERT Review Contractor, the CERT Documentation Contractor, and the CERT Statistical Contractor, and they work together to review a random sample of claims and determine an error rate for local Medicare, as well as Railroad Medicare. They do this by:
Requesting medical records from providers who submitted claims
Reviewing claims and medical records for compliance with Medicare coverage, coding and billing rules
The CERT program calculates an improper payment rate, and it also develops an improper payment rate by claim type, to measure Medicare (and Railroad Medicare’s) performance processing claims correctly.
Working together, these initiatives reduce the number of claims that are underpaid, overpaid or should never have been paid.
If you have any questions about your Railroad Medicare coverage, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. Members can sign up for email updates. To do so, visit Palmetto’s website at www.PalmettoGBA.com/RR/Me and click ‘Email Updates’ on the top of the webpage to start the process.
The start of a new year is the time for resolutions. Railroad retirees covered under Medicare can receive the help they need in making some of their resolutions a reality.
According to USA.gov, the top three New Year’s resolutions are:
Lose Weight
Volunteer
Quit Smoking
The year 2015 can be a year of change with the help of Medicare’s coverage of obesity counseling.
All Medicare patients with body mass indexes (BMI) of 30 or more are eligible for counseling if performed in a primary care setting – such as in a doctor’s office. When conducted in a doctor’s office, it can be coordinated with a personalized prevention plan. The patient will pay nothing for this service as long as the primary care provider accepts Medicare assignment. Patients should also ask questions if their doctor recommends other services to be sure that Medicare covers them.
Some of the covered counseling services include one face-to-face visit each week for the first month, one face-to-face visit every other week for months two through six, and then one face-to-face visit every month for the seventh through 12th months, as long as the patient has lost at least 6.6 pounds during the first six months.
Medicare is now covering counseling in a group setting for two to 10 people when conducted by providers in the following categories:
General practice
Family practice
Obstetrics/Gynecology
Pediatric Medicine
Geriatric Medicine
Nurse practitioner
Certified clinical nurse specialist
Physician’s assistant
Medicare is also tackling number three on the list of most popular New Year’s resolutions: quitting smoking. Smoking and tobacco-use cessation counseling is a benefit which offers up to eight face-to-face visits in a 12-month period for patients who have not been diagnosed with a smoking-related illness.
The counselor must be a qualified doctor or other Medicare-approved practitioner. The following resources are available to those considering quitting smoking:
National Network of Tobacco Cessation Quitline (1-800-Quit-Now or 1-800-784-8669)
If you have questions about Medicare’s coverage of obesity counseling or smoking/tobacco-use cessation, call the Railroad Medicare Beneficiary Contact Center at (800) 833-4455. Representatives are available Monday through Friday from 8:30 a.m. to 7 p.m. ET.
Email updates are available on Medicare’s website at www.PalmettoGBA.com/RR/Me. To register, look for ‘email updates’ under the ‘Stay Connected’ part of the lower left-hand side of the webpage.
You may also receive updates through Twitter or Facebook called ‘My RR Medicare’ located at www.facebook.com/myrrmedicare.
Palmetto GBA is conducting a Railroad Medicare Beneficiary Satisfaction Survey. The survey is designed to collect data on beneficiary satisfaction regarding its performance as Railroad Medicare’s contractor. The survey will be sent to a random sample of approximately 8,000 Railroad Medicare Beneficiaries.
The surveys will be included in an upcoming Medicare Summary Notice (MSN). Palmetto GBA is listening and wants to hear from you about the services we provide to you.
For additional information about the survey, click here.
When planning a foreign trip, it’s highly unlikely your first thought would be, “Will Medicare pay if I get injured or have a medical emergency before I get back home?”
Many patients think their Medicare benefits will provide coverage, wherever they go. Unfortunately, this isn’t true and can lead to costly, and avoidable, mistakes.
Generally, Medicare doesn’t pay for medical services to patients outside of the United States. Medicare describes the United States as the 50 states, the District of Columbia, Puerto Rico, Guam, American Samoa, the U.S. Virgin Islands, the Northern Mariana Islands, and the territorial waters adjacent to these areas.
“United States,” in this interpretation, would not include any United States Armed Forces bases. So whether you are heading to Europe, the Caribbean, or anywhere outside the U.S., you may wish to consider travel insurance. Here’s why: Medicare only pays, under very limited circumstances, for a limited number of services outside the United States.
Medicare won’t pay for medical treatment or prescription drugs, even if you receive them on board cruise ships, unless the ship is in U.S. territorial waters. “Territorial Waters” means the ship is in a U.S. port, or within 6 hours of when the ship arrived at, or departed from a U.S. port.
The Centers for Medicare and Medicaid (CMS) have listed the rare instances in which other coverage may exist, such as for:
Emergency inpatient hospital services if you fall ill in the U.S, but the closest hospital that can treat you is outside of the U.S.
Emergency treatment at a Canadian hospital if you are traveling straight through Canada (between Alaska and another state) and the closest hospital you can be treated at is in Canada.
Should the services meet criteria for payment in those situations, physician and ambulance services may be covered as part of, or immediately prior to, that stay. However, Medicare will not pay for transport back to the U.S. after a medical emergency that occurs outside of the U.S.
Knowing this, when you plan a trip abroad, you may want to look into what coverage you do have. Some Medigap or Medicare supplemental plans have travel-related benefits. If you don’t have a supplemental plan, or that plan does not pay for services you might receive outside of the United States, you may want to purchase a travel insurance plan that includes medical coverage.
Don’t let the expense of an unplanned medical emergency ruin your travels. Plan ahead and have a great trip!
If you have questions about your Medicare benefits, call Medicare’s toll-free Beneficiary Contact Center at (800) 833-4455, Monday through Friday, from 8:30 a.m. until 7 p.m. ET. Medicare also offers a TTY/TDD line at (877) 566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.
Visit Railroad Medicare’s website at www.PalmettoGBA.com/RR/Me. You can receive email updates about changes to the Railroad Medicare program by visiting its website and signing up in its ‘Stay Connected’ portion at the bottom left of the site.
If you find yourself in need of a doctor, and you don’t know if one practices near you, or if they participate in Medicare, and you have internet access, you can use the ‘Physician Compare’ tool at www.Medicare.gov.
Physician Compare is a website maintained by the Centers for Medicare and Medicaid Services (CMS), and it houses a wealth of information, including physicians’:
Names
Specialties
Gender
Addresses and phone numbers
Hospital affiliations
Medicare assignment status
Language spoken
If you don’t know what kind of doctor you need, you can use an advanced search and pick the part of your body that you would like a doctor to examine. The search tool asks more questions and leads you to a listing of doctors in your area who would be a good fit for you.
The website also provides you with maps and driving directions. If you have a MyMedicare.gov account you can save the search results in ‘your favorites’ (at www.MyMedicare.gov).
If you are looking for a practice/group of doctors by specialty, Physician Compare can find these for you, as well.
If you do not have access to the Internet, you can either call 1-800-MEDICARE or our Beneficiary Contact Center, and Customer Service Staff can do the search with you on the telephone. You can reach our toll-free Beneficiary Customer Service Line at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877-566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours Customer Service Representatives are available.
We encourage you to visit our Facebook page at https://www.facebook.com/myrrmedicare. We also invite you to join our listserv/e-mail updates. Just select the ‘E-Mail Updates’ in the ‘Stay Connected’ section on the lower left-hand side of our main webpage at www.PalmettoGBA.com/RR/Me.
The federal Medicare program provides hospital and medical insurance protection for railroad retirement annuitants and their families, just as it does for social security beneficiaries. Medicare has the following parts:
Medicare Part A (hospital insurance) helps pay for inpatient care in hospitals and skilled nursing facilities (following a hospital stay), some home health care services, and hospice care. Part A is financed through payroll taxes paid by employees and employers.
Medicare Part B (medical insurance) helps pay for medically necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services. Part B is financed by premiums paid by participants and by Federal general revenue funds.
Medicare Part C (Medicare Advantage Plans) is another way to get Medicare benefits. It combines Part A, Part B, and sometimes, Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare.
Medicare Part D (Medicare prescription drug coverage) offers voluntary insurance coverage for prescription drugs through Medicare prescription drug plans and other health plan options.
The following questions and answers provide basic information on Medicare eligibility and coverage, as well as other information on the Medicare program.
1. Who is eligible for Medicare?
All railroad retirement beneficiaries age 65 or over and other persons who are directly or potentially eligible for railroad retirement benefits are covered by the program. Although the age requirements for some unreduced railroad retirement benefits have risen just like the social security requirements, beneficiaries are still eligible for Medicare at age 65.
Coverage before age 65 is available for disabled employee annuitants who have been entitled to monthly benefits based on total disability for at least 24 months and have a disability insured status under social security law. There is no 24-month waiting period for those who have ALS (Amyotrophic Lateral Sclerosis), also known as Lou Gehrig’s disease.
If entitled to monthly benefits based on an occupational disability, and the individual has been granted a disability freeze, he or she is eligible for Medicare starting with the 30th month after the freeze date or, if later, the 25th month after he or she became entitled to monthly benefits. If receiving benefits due to occupational disability and the person has not been granted a disability freeze, he or she is generally eligible for Medicare at age 65. (The standards for a disability freeze determination follow social security law and are comparable to the medical criteria a person must meet to be granted a total disability.)
Under certain conditions, spouses, divorced spouses, surviving divorced spouses, widow(er)s, or a dependent parent may be eligible for Medicare hospital insurance based on an employee’s work record when the spouse, etc., turns age 65. Also, disabled widow(er)s under age 65, disabled surviving divorced spouses under age 65, and disabled children may be eligible for Medicare, usually after a 24-month waiting period.
Medicare coverage at any age on the basis of permanent kidney failure requiring hemodialysis or receipt of a kidney transplant is also available to employee annuitants, employees who have not retired but meet certain minimum service requirements, spouses, and dependent children. The Social Security Administration has jurisdiction of Medicare in these cases. Therefore, a social security office should be contacted for information on coverage for kidney disease.
2. How do persons enroll in Medicare?
If a retired employee, or a family member, is receiving a railroad retirement annuity, enrollment for both Medicare Part A and Part B is generally automatic and coverage begins when the person reaches age 65. For beneficiaries who are totally and permanently disabled, both Medicare Part A and Part B start automatically with the 30th month after the beneficiary became disabled or, if later, the 25th month after the beneficiary became entitled to monthly benefits. Even though enrollment is automatic, an individual may decline Part B; this does not prevent him or her from applying for Part B at a later date. However, premiums may be higher if enrollment is delayed. (See question 5 for more information on delayed enrollment.)
If an individual is eligible for, but not receiving an annuity, he or she should contact the nearest Railroad Retirement Board (RRB) office before attaining age 65 and apply for both Part A and Part B. (This does not mean that the individual must retire, if presently working.) The best time to apply is during the 3 months before the month in which the individual reaches age 65. He or she will then have both Part A and Part B protection beginning with the month age 65 is reached. If the individual does not enroll for Part B in the 3 months before attaining age 65, he or she can enroll in the month age 65 is reached, or during the 3 months that follow, but there will be a delay of 1 to 3 months before Part B is effective. Individuals who do not enroll during this “initial enrollment period” may sign up in any “general enrollment period” (Jan. 1 – March 31 each year). Coverage for such individuals begins July 1 of the year of enrollment.
3. Are there costs associated with Medicare Part A (hospital insurance)?
Yes. While individuals don’t have to pay a premium to receive Medicare Part A, recipients of Part A benefits are billed by the hospital for a deductible amount ($1,216 in 2014), as well as any coinsurance amount due and any non-covered services. The remainder of the bill from the hospital, as well as bills for services in skilled nursing facilities or home health visits, is sent to Medicare to pay its share.
4. What are the costs associated with Medicare Part B (medical insurance)?
Anyone eligible for Medicare hospital insurance (Part A) can enroll in Medicare medical insurance (Part B) by paying a monthly premium. The standard premium is $104.90 in 2014. Monthly premiums for some beneficiaries are greater, depending on a beneficiary’s or married couple’s modified adjusted gross income. The income-related Part B premiums for 2014 are $146.90, $209.80, $272.70, or $335.70, depending on the extent to which an individual beneficiary’s modified adjusted gross income exceeds $85,000 ($170,000 for a married couple), with the highest premium rates only paid by beneficiaries whose modified adjusted gross incomes are over $214,000 ($428,000 for a married couple).
There is also an annual deductible ($147 in 2014) for Part B services.
Palmetto GBA, a subsidiary of Blue Cross and Blue Shield, generally processes claims for Part B benefits filed on behalf of railroad retirement beneficiaries in the Original Medicare Plan (the traditional fee-for-service Medicare plan). An individual in the Original Medicare Plan should have his or her hospital, doctor, or other health care provider submit Part B claims directly to:
Palmetto GBA Railroad Medicare Part B Office P.O. Box 10066 Augusta, GA 30999-0001
Persons with questions about Part B claims under the Original Medicare Plan can contact Palmetto GBA as notated above.
5. Can Medicare Part B premiums increase for delayed enrollment?
Yes. Premiums for Part B are increased 10 percent for each 12-month period the individual could have been, but was not, enrolled. However, individu als age 65 or older who wait to enroll in Part B because they have group health plan coverage based on their own or their spouse’s current employment may not have to pay higher premiums because they may be eligible for “special enrollment periods.” The same special enrollment period rules apply to disabled individuals, except that the group health insurance may be based on the current employment of the individual, his or her spouse, or a family member.
Individuals deciding when to enroll in Medicare Part B must consider how this will affect eligibility for health insurance policies which supplement Medicare coverage. These include “Medigap” insurance and prescription drug coverage, and are explained in the answers to questions 6 through 8.
6. What is Medigap insurance?
Many private insurance companies sell insurance, called “Medigap” for short, that helps pay for services not covered by the Original Medicare Plan. Policies may cover deductibles, coinsurance, copayments, health care outside the United States and more. Generally, individuals need Medicare Part A and Part B to enroll, and a monthly premium is charged. When someone first enrolls in Medicare Part B at age 65 or older, he or she has a six-month “Medigap open enrollment period.” During this period, an insurance company cannot deny coverage, place conditions on a policy, or charge more for a policy because of past or present health problems.
7. Do Medicare beneficiaries have choices available for receiving health care services?
Yes. Under the Original Medicare Plan, the fee-for-service Medicare plan that is available nationwide, a beneficiary can see any doctor or provider who accepts Medicare and is accepting new Medicare patients.
However, a beneficiary may opt to choose a Medicare Advantage Plan (Part C) instead. These plans are managed by Medicare-approved private insurance companies. Medicare Advantage Plans combine Medicare Part A and Part B coverage, and are available in most areas of the country. An individual must have Medicare Part A and Part B to join a Medicare Advantage Plan, and must live in the plan’s service area. Medicare Advantage Plan choices include regional preferred provider organizations (PPOs), health maintenance organizations (HMOs), private fee-for-service plans and others. A PPO is a plan under which a beneficiary uses doctors, hospitals, and providers belonging to a network; beneficiaries can use doctors, hospitals, and providers outside the network for an additional cost. Under a Medicare Advantage Plan, a beneficiary may pay lower copayments and receive extra benefits. Most plans also include Medicare prescription drug coverage (Part D).
8. How do Medicare prescription drug plans work?
Medicare contracts with private companies to offer beneficiaries voluntary prescription drug coverage through a variety of options, with different covered prescriptions and different costs. Beneficiaries pay a monthly premium (averaging about $32 in 2014), a yearly deductible (up to $310 in 2014) and part of the cost of prescriptions. Those with limited income and resources may qualify for help in paying some prescription drug costs.
The Affordable Care Act requires some Part D beneficiaries to also pay a monthly adjustment amount, depending on a beneficiary’s or married couple’s modified adjusted gross income. The Part D income-related monthly adjustment amounts in 2014 are $12.10, $31.10, $50.20, or $69.30, depending on the extent to which an individual beneficiary’s modified adjusted gross income exceeds $85,000 ($170,000 for a married couple), with the highest amounts only paid by beneficiaries whose incomes are over $214,000 ($428,000 for a married couple).
To enroll, individuals must have Medicare Part A and live in the prescription drug benefit plan’s service area. Beneficiaries can join during the period that starts 3 months before the month their Medicare coverage starts and ends 3 months after that month. There may be a higher premium if an individual doesn’t join a Medicare drug plan when first eligible. In most cases, there is no automatic enrollment to get a Medicare prescription drug plan. Individuals enrolled in Medicare Advantage Plans will generally get their prescription drug coverage through their plan.
9. Where can I get more information about the Medicare program?
Railroad retirement beneficiaries should contact the RRB toll-free at (877) 772-5772 for general information on their Medicare coverage.
More detailed information on Medicare’s benefits, costs, and health care options is available from the Center for Medicare & Medicaid Services (CMS) publication Medicare & You, which is mailed to Medicare beneficiary households each fall and to new Medicare beneficiaries when they become eligible for coverage. Medicare & You and other publications are also available by visiting Medicare’s website, www.medicare.gov, or by calling the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227).
When Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. In 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible.
This legislation stopped Medicare from making payment if the payment had already been made, or would be expected to be made, by group health plans or workers’ compensation plans.
Medicare pays first when:
You have retiree insurance (from either you or your spouse’s former employment)
You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has less than 20 employees
You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has less than 100 employees
You’re also receiving Medicaid benefits
If you have group health care plan coverage that is primary to Medicare (pays first), it will continue to do so until it pays up to the limits of its coverage. Then Medicare becomes primary.
Medicare pays second when:
You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has 20 or more employees
You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has 100 or more employees
You have end-stage renal disease (ESRD) and you are in the first 30 months of your Medicare eligibility. Medicare pays first after that.
You’re covered by no-fault or liability insurance for any services related to an accident
For a detailed explanation of how Medicare works with other insurance coverage, go to www.medicare.gov/publications and view the booklet “Medicare and Other Health Benefits: Your Guide to Who Pays First.”
Insurance that pays after Medicare is referred to as supplemental insurance. Your retiree coverage may act as supplemental insurance, or you may purchase a Medigap policy from a private insurance company. For information about Medigap policies, visit www.medicare.gov/publications and view the booklet “Choosing a Medigap Policy: A Guide to People with Medicare.”
Medicare works with supplemental insurance companies through a process called “crossover.” Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance company after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.
In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.
If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and health insurance claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.
If your supplemental insurance does not participate in crossover with Medicare, you will be responsible for ensuring your insurance receives information about claims Medicare has processed. Many providers will file claims to your supplemental insurance after Medicare has processed your claim. If you provider will not file to your supplemental insurance, contact the plan to verify what information they will need to process a claim. Many supplemental insurance plans will ask you to send a copy of your MSN. If you need an MSN, you may request one from our customer service unit.
If you have questions about how Medicare paid a claim as primary or secondary, please call our toll-free Customer Service Line at (800) 833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at (877) 566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.
It’s that time again. Flu season is upon us and the flu shot is available to be taken now. There are between 135 and 139 million vaccinations available this year. Medicare Part B (including Railroad Medicare) normally pays for one flu shot per flu season.
There are two ways to take the vaccine – by injection or nasally – and there are different types of vaccine options. The vaccine traditionally protects against three or four different kinds of flu viruses: two that are influenza A and one or two that are influenza B.
Several of the vaccines are egg-based which means they’re manufactured in eggs or with egg protein. Those who are sensitive to eggs should discuss with their doctor which type of flu shot they should get.
If you are in one of the following categories, you should get a flu shot:
50 years or older;
At high risk of developing complications from the flu, such as pneumonia;
Have asthma, diabetes or chronic lung disease or other conditions;
Are a resident of a nursing home.
You can receive your vaccination at clinics, pharmacies, health departments or your doctor’s office. If your provider accepts Medicare, then Railroad Medicare should also be accepted. If they have any questions, they can call the Provider Contact at (888) 355-9165 from 8:30 a.m. to 4:30 p.m.
If you have questions about your coverage call the Railroad Medicare Beneficiary Contact Center at (800) 833-4455 between 8:30 a.m. and 7 p.m., EST, Monday through Friday or visit www.PalmettoGBA.com and click on “Railroad Beneficiaries” along the left side.
Medicare beneficiaries will see their standard Medicare Part B monthly premium increase by $5 monthly to $104.90 beginning in January.
A small number of beneficiaries will continue to pay higher premiums based on their modified adjusted gross income, which depends on the extent to which an individual beneficiary’s modified gross income exceeds $85,000 ($170,000 for a married couple). Only about 5 percent of Medicare beneficiaries pay higher rates.
As for Medicare Part D prescription drug coverage, premiums vary among plans. But the Affordable Care Act requires Part D beneficiaries whose modified adjusted gross income exceeds $85,000 ($170,000 for married couples) to pay a monthly adjustment amount. They will pay the regular plan premium on their Part D plan and pay an income-related adjustment.
Beneficiaries affected by the 2013 Part B and D income-related premiums will receive a notice before the end of December. The notice will include an explanation of the circumstances where a beneficiary may request a new determination.
This article, provided by Palmetto GBA Railroad Medicare, outlines the various “parts” of Medicare and explains which types of services are covered under each.
What Is Part A?
Part A includes inpatient hospital, skilled nursing facility (or SNF), nursing home, hospice and home health services care. It also includes long-term care acute care (LTAC). Part A Medicare claims are processed by the local Medicare administrative contractor for your state. Railroad Medicare processes your Part B claims, while your local Medicare administrative contractor handles your Part A claims.
What is Part B?
Part B services include medically necessary services and preventive services provided by doctors/physicians/surgeons and practitioners (such as nurse practitioners, physician assistants, qualified clinical psychologists, clinical social workers, certified midwifes and certified registered nurse anesthetists). Other providers and suppliers in the Part B program include chiropractors, podiatrists, ambulance services, and laboratories. Claims for these types of services are processed by Railroad Medicare/Palmetto GBA in Augusta, Ga.
What is Part C?
Part C is Medicare Advantage plans, such as Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). These plans are offered by private companies that contract with Medicare to cover your Part A and B benefits. Other Medicare Advantage Plans include:
* Private Fee-For-Service (PFFS) – PFFS are offered by private insurance companies and let you receive health care from any doctor or other health care provider or hospital in the PFFS plan. Prescription drug coverage may also be offered by a PFFS plan.
* Special Needs Plans (SNP) – SNP limits membership to patients with specific illnesses and customizes their benefits to serve the needs of their members. For more information on SNP, please visit www.Medicare.gov.
* Medical Savings Accounts (MSA) – MSAs have a high deductible and in many cases only pays for covered Part A and B services once you have reached your deductible. The plan deposits funds (which typically are less than the deductible) into a designated account to pay for your health care services during the year.
What is Part D?
Part D is coverage for prescription drugs, and like Part C, the program is administered by private insurance companies. Part D plans have their own list of covered medicines, with a tiered pricing system. This means that some drugs, such as generics, may be in the lowest tier and have the lowest copayment. Drugs in the highest tiers would have the highest copayment. If you sign up for a Part D plan when you are first eligible you avoid paying a penalty. A penalty would be assessed if you don’t join when you were first eligible and you don’t have other drug coverage or don’t receive “Extra Help”. Beneficiaries with limited income and assets may qualify for “Extra Help” to help pay for prescription drugs. This program is administered through the Social Security program and Medicare. For more information, please visit www.SSA.gov/prescriptionhelp/.
DMEPOS
DMEPOS stands for coverage of Durable Medical Equipment, Prosthesis and Prosthetic Devices, Orthotics and Supplies. DMEPOS would include items such as walkers, wheelchairs, diabetic shoes, and hospital beds, to name a few. Claims for these and many more products are filed to Durable Medical Equipment (DME) Medicare Administrative Contractors. Railroad Medicare doesn’t handle DME claims.
An example of how the letters work together
An example of how one procedure is covered by multiple parts of Medicare is for individuals receiving a cardiac pacemaker. The actual pacemaker (which is a DMEPOS — prosthetic device) is billed to your local DME Medicare administrative contractor. Hospital charges fall under your Part A benefit, and the physician’s fee, including post-surgical care, is billed to Part B.
If you have questions about your Railroad Medicare (Part B) claims, call Palmetto’s beneficiary contact center at (800) 833-4455, Monday through Friday, 8:30 a.m. until 7 p.m. ET. For the hearing impaired, call TTY/TDD at (877) 566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available. You can also visit Palmetto’s website at www.PalmettoGBA.com/rr/me.
For more information about the general Medicare program, or specifically about Part C or Part D, you can contact your local state health insurance counseling and assistance program, or SHIP. SHIP is a free program offered by all 50 states, as well as Guam, Puerto Rico and the Virgin Islands. SHIP counselors can help you learn more about the Medicare program and Medicare supplemental plans, as well as other long-term insurance options. To find a SHIP office for your state, visit http://www.medicare.gov/contacts/organization-search-criteria.aspx and enter “SHIP — State Health Insurance Assistance Program” and select your state. Or you may call (800) MEDICARE for more information.
For many years, the Centers for Medicare & Medicaid (CMS) has funded programs to reduce claims payment errors (either paying too much, paying too little or payments being made when none should be). Some of these programs are handled through systematic checks that look for anomalies and mismatched services, and some are handled through clinical reviews of specific claims. 
When planning a foreign trip, it’s highly unlikely your first thought would be, “Will Medicare pay if I get injured or have a medical emergency before I get back home?”
The federal Medicare program provides hospital and medical insurance protection for railroad retirement annuitants and their families, just as it does for social security beneficiaries. Medicare has the following parts:
When Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. In 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible.