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Ambulances transport critically ill or injured passengers to hospitals every day. They also take patients with non-emergency conditions to hospitals, critical access hospitals, skilled nursing facilities, nursing homes and other medical facilities to treat serious health conditions. 

Some of these transports are scheduled in advance, and some are not. Both emergency and non-emergency ambulance services may be covered by Medicare if it is established that using any other kind of transportation would endanger your health.

When Medicare establishes that other means of transportation would harm your health, “medical necessity” is proven. Medicare determines medical necessity by examining the notes the ambulance personnel make while documenting your trip.  For non-emergency services, Medicare also requires a signed statement from your doctor indicating that you must be transported by an ambulance due to your condition.

Sometimes the ambulance company will ask you to sign an Advance Beneficiary Notice of Non-coverage (ABN). They can only do this for non-emergency services, and only when they believe that Medicare won’t pay for the service.

Always read an ABN carefully. An ABN explains that if you want the service, you will assume payment responsibility if Medicare doesn’t cover the transport. The ambulance company can ask you to pay at the time of the service. If you refuse to sign the ABN, the ambulance company can still transport you, but you may still be responsible for the service if Medicare doesn’t deem it medically necessary.

Limitations on Medicare’s Coverage

Nearest Facility

Medicare pays for medically necessary ambulance transports to the closest facility that can provide you with the level of care or services you require. If you want to be taken farther way, Medicare will only pay the mileage to the nearest appropriate facility. You will be responsible for the excess mileage costs.

Other Means of Transportation

Medicare can only pay for ambulance transports when it is proven that any other means of transportation would harm your health, even if other ways of transportation are not available. 

Required Documentation

Written Doctor’s Order (Non-Emergency Services)

To establish medical necessity, Medicare requires ambulance suppliers to submit documentation that shows any other means of transportation would have harmed your health at the time of the service. For most non-emergency services, a written doctor’s order is required. Medicare regulations also state that the presence of a signed physician’s order does not, in and of itself, prove medical necessity. It’s the total picture the ambulance company paints of what happened during the transport and why their services were needed that allows Medicare to pay.

Your Signature (All Services)

In order to file the claim to Medicare, the ambulance company must obtain your signature (or that of an authorized representative). Your signature allows the ambulance company to accept Medicare assignment and also shows that you are allowing them to bill Medicare for the service. You do not have to provide your signature at the time of the transport, but you must do so within the claims filing time period (within 12 months of the date of the service). 

If you or your representative refuses to sign, then the ambulance company can’t bill Medicare, and you will be responsible for the full amount of the transport. If you change your mind any time during the claims filing period, you can contact the ambulance company.  

If you are unable to sign and an authorized representative can’t be found, then an ambulance employee present during the trip would need to provide a signed statement that includes:

* The date and time of the transport

* Why you were unable to sign

* An indication that no legally authorized person was available to sign on your behalf

* The name and location of the facility you were transported to

An employee from the receiving facility would also need to sign a statement that includes your name and the date and time you were brought there. If the ambulance company doesn’t obtain this information from the facility, with your permission, they can send Medicare a signed patient care report, your hospital registration or admission sheet or other hospital records that would support why you were not able to sign on your own.

What You Can Do If Medicare Doesn’t Pay

If Medicare denies your claim and you don’t agree, you can file an appeal. Your appeal rights are on the back of the Medicare Summary Notice (MSN) that is sent to you from Medicare.

There are five different levels in the appeals process. If you don’t agree with the first level of appeal, you can request the second level. If you still don’t agree, you can request the third level and then the fourth, and finally the fifth.

* 1st level – Redetermination – You need to file a redetermination within 120 days from the date of your MSN. To file an appeal, you can follow the instructions on your MSN by signing and returning it to our office at the following address:

Railroad Medicare – Palmetto GBA
Attn: Redeterminations
P. O. Box 10066 
Augusta, GA 30999  

* 2nd level – Reconsideration – This is the second level of appeals and is requested if don’t agree with the redetermination decision.  You have to ask for a Reconsideration within 180 days from the date of your redetermination letter. The second level of appeals is handled by the Qualified Independent Contractor (QIC), which is separate from Palmetto GBA.  Information about the QIC is included on your Redetermination decision letter from Railroad Medicare.

* 3rd level – Administrative Law Judge (ALJ) – If you don’t agree with the QIC’s decision, you can request a hearing by the ALJ.  You have to file a request for an ALJ hearing within 60 days from the date of your reconsideration letter. The bill you are appealing must be more than $130.

* 4th level – Medicare Appeals Council – If you disagree with the ALJ’s decision, you have 60 days after you get your decision to ask for a review by the Medicare Appeals Council.
* 5th level – Review by a Federal District Court– Follow the directions in the Medicare Appeals Council decision if you’d like to request a review by a Federal district court. 

It is important to remember that the decision letter you receive at each level of appeal will explain additional appeal rights you may have. You should read these decision letters carefully.
 
If you have questions about a Railroad Medicare claim, you can call a toll-free customer service line at (800) 833-4455, Monday through Friday, from 8:30 a.m. until 7:00 p.m. Eastern time. 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.

U.S. Capitol Building; Capitol Building; Washington D.C.Public transportation funding, transportation jobs, workplace safety, Railroad Retirement and Medicare are under a mean-spirited and sustained attack by congressional conservatives who are trying to muscle their agenda through Congress prior to the November elections.

The UTU and Sheet Metal Workers International Association – now combined into the Sheet Metal, Air, Rail and Transportation Workers (SMART) – along with other labor organizations, public interest groups, congressional Democrats and moderate Republicans are working on Capitol Hill to block these attempts, which could be devastating to working families.

UTU National Legislative Director James Stem and SMWIA Director of Governmental Affairs Jay Potesta outlined the conservatives’ agenda that has surfaced in proposed congressional transportation reauthorization and budget legislation:

* Cut $31.5 billion in federal transportation spending, which would threaten some 500,000 American jobs.

* Eliminate federal spending for Amtrak and expansion of intercity rail-passenger service and high-speed rail, with a direct impact on jobs associated with that service.

* Gut federal spending for the Alaska Railroad, which would force elimination of scores of train and engine workers represented by the UTU.

* Delay implementation of positive train control, which is a modern technology to reduce train accidents and save lives and limbs.

* Eliminate federal spending for expansion of local and regional transit service as Americans scramble to find alternatives to driving in the face of soaring gasoline prices. The federal spending cut would prevent the return to work of furloughed workers from budget-starved local transit systems and likely cause layoffs of still more transit workers.

* Encourage privatization of local transit systems, which would open the door for non-union operators eager to pay substandard wages and eliminate employee health care insurance and other benefits.

* Remove any requirement for shuttle-van operators, whose vehicles cross state lines, from paying even minimum wage or overtime – a proposal, which if enacted, could lead to applying that legislation to interstate transit operations.

* Eliminate Railroad Retirement Tier I benefits that exceed Social Security benefits even though railroads and rail employees pay 100 percent of those benefits through payroll taxes, with no federal funds contributing to Tier I benefits that exceed what is paid by Social Security.

* Replace direct federal spending on Medicare in favor of handing out vouchers to be used to purchase private insurance, which will undercut the viability of Medicare.

* Provide large tax breaks to millionaires and preserve tax breaks for Wall Street hedge funds that cater to the wealthy, while cutting by two-thirds federal assistance to veterans and public schools.

The UTU member-supported political action committee (PAC) is helping to fund election campaigns by labor-friendly candidates, and a labor-wide “get out the vote” drive will go door-to-door across America in support of labor-friendly candidates in advance of November elections.

In the meantime, UTU and SMWIA legislative offices will continue their education campaign on Capitol Hill, visiting congressional offices to explain the economic devastation the current conservative agenda would impose on working families.

The head-cold and flu season is upon us, making it time to lower your risk of disease and illness by receiving a flu shot and pneumonia vaccine – and if you or your spouse is covered by Medicare, you won’t bear the cost and do not require a doctor’s referral.

The flu shot is an annual event, as the flu vaccine is formulated each flu season for the most probable flu virus.

You may only reqire one pneumonia shot in your lifetime, and if you are at least 65, have a chronic illness such as diabetes, or have a heart or lung disease, your risk of contracting pneumonia is higher.

Health care providers suggest you consult your physician about health risks and your need for these shots.

If you are a railroader and covered by Medicare, it is important that billing go to Railroad Medicare and that your Railroad Medicare card is on file.

Providers new to Railroad Medicare and those who have supplied services to Railroad Medicare patients for years may have new staff that might file your claims to the wrong Medicare contractor in error. This can happen when they don’t notice that your Health Insurance Claim Number (HICN) is different from Social Security Administration (SSA) Medicare patients. 

Because Railroad Medicare HICNs vary from the SSA Medicare format, it’s important that your provider’s staff review your card to verify the number prior to billing Railroad Medicare.

Railroad Medicare beneficiaries have the same benefits as Social Security beneficiaries, but only one national carrier — Palmetto GBA Railroad Medicare, which processes all Railroad Medicare Part B claims.

If you are concerned that your provider is having problems submitting your claim correctly, call the Palmetto GBA Beneficiary Contact Center at (800) 833-4455, or (877) 566-3572 for those with hearing impairments.

If you have non-claim specific questions about your coverage with Railroad Medicare, you may visit the “My RR Medicare” page on Facebook at www.facebook.com/myrrmedicare.

 

The Medicare Part B premium will rise by $3.50 monthly to $99.90 monthly beginning Jan. 1, according to the Centers for Medicare & Medicaid Services. This is the first increase in the Part B premium in two years.

For Medicare participants who first enrolled in 2010 and 2011, and have been paying as much as $115.40 monthly, the monthly premium will drop to to $99.90.
  
Because Medicare premiums are adjusted for higher-income retirees, some beneficiaries (fewer than 5 percent of all beneficiaries) will pay higher premiums in 2012, reaching as high as $319.70 monthly for individuals whose adjusted gross income exceeds $428,000 (married couple).

Only higher-income beneficiaries will pay an increased amount for Medicare Part D prescription drug coverage in 2012.
  
Additional information on Medicare coverage, including specific benefits and deductibles, can be found at http://www.medicare.gov/ 

Would you accept a job paying $1 million to count out $2 billion in $1 bills?

Think again, because working a 40-hour week and counting out $1 per second, you would require 266 years to count out the $2 billion total.

Now that you have an idea how much $2 billion is, consider that in the 12 months ending Sept. 30, 2010, the federal government, through the Department of Justice, recovered $2.6 billion in Medicare health care fraud judgments and settlements from 726 separate defendants.

This $2.6 billion total has exploded from $490 million in 1999, meaning that Medicare health care fraud is on the rise, according to PalmettoGBA, which administers Railroad Medicare.

As we struggle to preserve Medicare – and keep a lid on what we, as current and future retirees must pay for its coverage — it is necessary to do all we can to keep a lid on Medicare inflation.

We can help keep those costs down and help preserve Medicare by recognizing, reacting to and reporting Medicare health care fraud.

Here is what you can do:

  • Examine carefully your Medicare Summary Notices (MSNs).
  • Be alert for charges for services you didn’t receive, double billings for the same service, and procedures or services not ordered by your physician.
  • Keep your Medicare card in a safe place. If it becomes lost or stolen, notify your Medicare provider immediately.

If you see a charge or a date of service that is incorrect, first call your provider and ask about it. If the billing is not corrected, or if you suspect a pattern of improper billing, call the Department of Health and Human Services Medicare fraud hotline at (800) 447-8477, which will initiate an investigation and keep your identity confidential.

For more information on Medicare fraud, visit www.PalmettoGBA.com/rr/me

If we don’t take the initiative to help keep Medicare costs down, we place the future of Medicare – and our own health care futures – in jeopardy.

The Railroad Retirement Board will begin June 1 to withhold from benefits checks premiums for Medicare Part C (Medicare Advantage plans) and Medicare Part D (prescription drug plans).

Withholding is voluntary, and beneficiaries should contact their plans to request withholding by the Railroad Retirement Board of these premiums from their monthly benefits payments.

Part C and Part D premiums vary according to the plan and provider.

Note that a new federal law requires some Part D beneficiaries also to pay an additional monthly adjustment amount, depending on a beneficiary’s or married couple’s modified adjusted gross income.

While the RRB will be able to deduct the regular Part D premiums for individuals who elect to have them withheld from their benefits payments, Part D enrollees subject to the monthly adjustment amount will continue to receive a bill for that portion as the Railroad Retirement Board says it is unable to deduct those amounts from benefits at this time.

The Part D income-related monthly adjustment amounts are $12, $31.10, $50.10 or $69.10, depending on the extent to which an individual beneficiary’s modified adjusted gross income exceeds $85,000, or a married couple’s income exceeds $170,000. The Social Security Administration determines if a monthly adjustment amount is due, based upon the most recent tax return information available from the IRS.

The Railroad Retirement Board also reminds Medicare beneficiaries that the annual enrollment period for Part C and Part D coverage will be between Oct. 15 and Dec. 7 this year, rather than Nov. 15 through Dec. 31, as it was in previous years. Changes and enrollments made during this period will still be effective Jan. 1, 2012.

Federal legislation affecting how Medicare reimburses physicians requires Medicare providers to reprocess claims dating back more than a year.

This reprocessing, required by federal law, may result in your receiving a refund for Medicare services you received in 2010, or your being billed for additional amounts under your co-pay obligation. In some cases there will be neither a refund nor a balance due.

Because of volume, the reprocessing of Medicare claims by your Medicare provider may continue through February 2012.

To identify reprocessed claims, scan your Medicare Summary Notice for a “5” appearing as the first digit of claim numbers. If there is a balance due, your Medicare provider will notify you directly; and you will receive, directly from your Medicare provider, any refunds due.

For Railroad Medicare beneficiaries, questions should be directed to the Railroad Medicare Beneficiary Contact Center by calling (800) 833-4455 — or the hearing-impaired line, (877) 566-3572 — between 8:30 a.m. to 7 p.m. Eastern Time.

Those not covered by Railroad Medicare should call their Medicare provider.

If you think Medicare should have paid for an item or service, or did not pay enough, you have 120 days from the date you receive your Medicare Summary Notice to file an appeal. Instructions on filing an appeal appear on your Medicare Summary Notice.

For Railroad Medicare recipients, the claim should be filed with:

Railroad Medicare — Palmetto GBA
Attn: Redeterminations
P.O. Box 10066
Augusta, GA 30999

More information on Railroad Medicare may be found at

www.PalmettoGBA.com/RR

by clicking on the link, “Additional information is available for Railroad Medicare Beneficiaries.”

Railroad Medicare beneficiaries may also sign up at that website for email updates.

Many physicians and medical practitioners are choosing to withdraw from participation in Medicare. This has a direct financial impact on all UTU members who are retired or intend to retire in the near future.

If you are eligible for Medicare, and your physician or medical practitioner withdraws from participation in Medicare, you are faced with a choice of signing a binding contract for continued medical services or choosing a physician who does participate with Medicare.

While Palmetto GBA, which administers Railroad Medicare, provided the following information, this alert also affects airline and bus members covered by Medicare.

If you are covered by Medicare, and your physician or medical practitioner has withdrawn or withdraws from participation in Medicare, the physician or medical practitioner will ask you to sign a contract for future services that would have been covered by Medicare prior to the physician or medical practitioner withdrawing from Medicare participation.

Once you sign the contract, Medicare will not pay for any services provided by that physician or medical practitioner. Additionally, no Medicare payment may be made to you for items or services provided directly by a physician or practitioner who has opted out of Medicare.

The contract you will be asked to sign is a binding agreement that you give up Medicare payment for services furnished by the physician or medical practitioner and that you agree to pay from your own pocket the physician or medical practitioner without regard to any limits that would otherwise apply to what they charge.

The only exception is in an emergency or urgent care situation.

Even if you sign such a contract with your physician, you may still receive services from other physicians and practitioners who are participating with Medicare.

“Physician” means doctors of medicine, doctors of osteopathy, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine and doctors of optometry.

“Medical practitioner” means physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, registered dietitian and nutrition professional.

Not affected are chiropractors, physical therapists and occupational therapists. They are not permitted to withdraw from Medicare participation.

If you are asked to sign a contract with a physician or medical practitioner who withdraws from Medicare participation, the contract must:

  • Be in writing and in print large enough so you can read it.
  • State whether the physician or medical practitioner is excluded from Medicare.
  • State that you or your legal representative accept full responsibility for payment of charges for all services provided by the physician/practitioner.
  • State that the you or your legal representative understand that Medicare limits do not apply to what the physician/practitioner may charge for items or services provided by the physician/practitioner.
  • State that you or your legal representative agree not to submit a claim to Medicare or to ask the physician or medical practitioner to submit a claim to Medicare.
  • State that you or your legal representative understand that Medicare payments will not be made for any items or services furnished by the physician or medical practitioner that would have otherwise been covered by Medicare if there was no contract and a proper Medicare claim had been submitted.
  • State that you or your legal representative are entering into the contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare.
  • State that you are not compelled to enter into contracts that apply to other Medicare-covered services provided by other physicians or practitioners who have not withdrawn from Medicare participation.
  • State the expected or known effective date and expected or known expiration date of the withdrawal period.
  • State that you or your legal representative understand that Medigap plans do not — and that other supplemental plans may elect not — to make payments for items and services not paid for by Medicare.
  • Be signed by you or your legal representative and by the physician or medical practitioner.
  • Not be entered into by you or your legal representative during a time when you require emergency care services or urgent care services.
  • Be provided to you (photo copy is acceptable) or to your legal representative before items or services are furnished to you under the terms of the contract; and be made available to the Centers for Medicare and Medicaid upon request.

Staying with, or going to, a physician who does not participate in Medicare is a difficult choice.

Retirees covered by Railroad Medicare may call the Railroad Beneficiary Contact Center at (800) 833-4455 or TTY at (877) 566-3572 to obtain names of physicians and medical practitioners in their area who participate in Medicare.

Those not covered by Railroad Medicare should contact their Medicare provider.

For more information on Railroad Medicare, sign up for email updates at :

www.palmettogba.com/medicare

Select “e-mail updates” under the “Stay Connected” section. You also may receive updates through Railroad Medicare’s Twitter or Facebook page by going to:

www.facebook.com/#!/myrrmedicare

 

The Centers for Medicare & Medicaid Services says that while the standard monthly Part B premium will rise to $115.40 in 2011, most Medicare beneficiaries will not see an increase in their monthly Part B premiums.

This is because of a hold-harmless provision in current law that will freeze Part B premiums at the amount paid in 2010.

It is those who newly enrolled in Medicare Part B during 2010 who will pay the new $115.40 monthly premium in 2011.

Additionally, those who do not have their Part B premiums withheld from Railroad Retirement or Social Security payments, or those subject to income-related additional premium amounts will pay a higher premium in 2011.

The income-related additional premium threshold is annual adjusted income of $85,000 for individuals and $170,000 for married couples.

The Centers for Medicare & Medicaid Services estimates that only about 5 percent of Medicare beneficiaries with Part B will pay higher premiums in 2011 because of their higher annual incomes.

As for Medicare Part D prescription drug coverage plans, those premiums vary from plan to plan.

Beginning in 2011, the Affordable Care Act requires Medicare Part D participants, whose modified adjusted gross incomes exceed the $85,000 and $170,000 thresholds, to pay a second premium in addition to the standard Plan D premium.

Medicare beneficiaries affected by the 2011 Part B and D income-related premiums will receive a notice from the Social Security Administration with further details on the higher Part B and Part D premiums they will face.

Medicare is the primary health insurance for retirees and their spouses. It is available for those over age 65, those under 65 with certain disabilities, and those of any age with permanent kidney failure. It consists of Parts A, B, C and D.

Part A helps cover inpatient care in hospitals and a skilled nursing facility, hospice and home health care.

Part B helps cover doctors’ services, hospital outpatient care and home health care, as well as some preventive services to help maintain your health and to keep certain illnesses from getting worse.

Part C is a Medicare advantage plan similar to an HMO or PPO — health plans run by Medicare-approved private insurance companies. Medicare advantage plans generally include Parts A, B and D.

Part D is a prescription drug program provided by a Medicare-approved private insurance company to help cover the cost of prescription drugs.

You should enroll in Medicare Parts A, B and D when you are first eligible. If you delay enrollment, you will be subject to additional costs for the coverage.

Railroad employees should call the Railroad Retirement Board’s toll-free information line at 877-772-5772 for enrollment and other information, or Palmetto GBA at 800-833-4455.

Non-railroad employees should call Medicare at 800-633-4227, or visit https://www.medicare.gov.

Medicare can send you a handbook, “Medicare & You,” explaining all aspects of Medicare, or the handbook may be ordered or downloaded at the Medicare website.