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 What is a Co-Pay?
When products or services are NOT covered 100% by an insurance carrier, part of the expense is paid for by the patient.
How Much is the Co-Pay For This Product/Service?
Generally the co-pay amount for a primary payor (set by the insurance carrier) is in the
form of a percentage or fixed dollar amount of the total allowable charge for that particular item or service. In the case where the patient has a Medicare coinsurance policy (such as
AARP or BC/BS 65 Special) the co-payment amount is after Medicare pays 80% of the total allowable charge for that particular item or service. If the coinsurance carrier pays
only part of the 20% after Medicare, then the remaining balance is the patient's responsibility.
To calculate a co-payment if you only have a primary insurance you must take the
provider's billable amount (or the insurance carriers maximum allowable amount, whichever is less) and multiply it times the co-pay percentage you are responsible for.
Example:
$195.00 Providers Billable Amount
$150.00 Insurance Carriers Maximum Allowable Amount
20% Co-Pay Percentage
Step 1: $150.00 x 20% (.20) = $30.00 your co-pay amount
To calculate a co-payment if you have a secondary insurance after Medicare you must take Medicare's allowable amount for that particular product or service (available from
Medicare or the provider) and multiply it times 20% (the Insurance carrier's responsibility after Medicare's payment) and then multiply that amount by the co-pay percentage you are responsible for.
Example:
$195.00 Providers Billable Amount
$150.00 Medicare's Allowable Amount
10% Co-Pay Percentage
Step 1: $150.00 x 20% (.20) = $30.00
Step 2: $30.00 x 10% (.10) = $3.00 your co-pay amount
Why do my invoices come so long after the actual date I receive the product/service?
Sometimes it can take up to six months after the initial date of service to gather all of the documentation needed to submit a claim to your insurance carrier. During that time any
one of the following could occur..
- If the Doctor doesn't sign the Certificate of Medical Necessity immediately, which can take 30 days
- If Medicare rejects the claim because certain information is missing, which can take 7 days
- If the claim needs to be resubmitted, which can take 14 days
- If the claim needs to be reviewed, which can take 45-60 days
Remember, that the provider is not charging you at the time of delivery (because you have coinsurance that may cover the co-payment) and when the provider gets paid they have
incurred many expenses involved with the product/service that was provided in good faith to you.
NOTE: The claim can be submitted as late as 15 months after the date of service at which
time the patient is still responsible for the payment of any coinsurance and/or denied products/services.
How do I decide if I want the capped rental item to be purchased
or rented from Medicare?
After the first ten months of rental billing, the option to continue renting or purchase the
equipment must be made and the provider must notify Medicare by the 12th month of billing.
If you choose to have the product continue renting , the provider will receive, from
Medicare, a total of 15 months of rental payments. After which time the provider will bill Medicare and your coinsurance every six months as maintenance and service as long as
you continue to rent the product. (Remember, if you have a co-pay amount associated with this product, it will be due every six months).
NOTE: The title to the equipment will remain with your provider.
If you choose to have the product purchased for you, the provider will receive, from Medicare, a total of 13 months of rental payments. From then on you will be responsible
for any maintenance and repairs on the product as charged by the provider for parts and labor. (Some providers will not accept assignment on the product repairs, but will submit your receipt to Medicare).
NOTE: The title to the equipment will transfer to you once the provider has received all payments (inlcluding all co-payments) for the product's first 13 months of rental.
Does Medicare cover this product?
Medicare has criteria that it uses to decide if the product or service is covered. The Medicare Screening List
is a summary of some of the products that are more commonly used and the criteria used by the Durable Medical Equipment Regional Carrier to decide if payment will be made.
NOTE:
Even if the criteria is met, there are other things that Medicare (and other insurance carriers) take into consideration such as: did this patient already have this
product bought within that last few years; does this patient own a piece of equipment that is similar in nature.
After my Doctor says I need a piece of equipment, what's next?
Investigate the product...
Use the Internet or visit a showroom to get information about the product. Find out the
different features, accessories, manufacturer's warranty, and the cost to you?
Investigate the provider...
Ask your friends and relatives if they've ever used a medical products company. Did the
provider have good service? Did the provider train them on how to use the equipment? Did the equipment operate properly? If not, did the provider replace it in a timely manner?
Did the provider have 24 hour emergency service? Were the products delivered quickly?
Does my Insurance cover this?
First ask your provider if they accept the insurance plan that you have (i.e. Medicare, Major Medical, HMO, etc.). Then, do one of the following:
For a Commercial Insurance Carrier, you should first verify that the specific product ordered is covered. When calling, the following should be asked: Is this product (give the
name) covered?; Do you follow Medicare coverage guidelines? (If so, then see the Medicare Screening List); Do I have a co-payment with this product?; What is the
maximum amount (or rental period) that you will pay for this product?
For Medicare, if the product meets the coverage criteria (See Medicare Screening List), the
paperwork is gathered to provide information to Medicare and the product has not been purchased recently for the patient (or some other unforseen disqualifying information)
then Medicare should pay for the product/service (and the deductible would be your responsibility).
If you have a Medicare Secondary Insurance, you should verify that the specific product
being ordered is covered. When calling, the following should be asked: Is this product (give the name) covered?; Do I have a co-payment with this product? Do you cover the
Medicare deductible?; What is the maximum amount (or rental period) that you will pay for this product?
What happens when the patient is done using the rental equipment? (Hospital bed, wheelchair, nebulizer, oxygen, etc.)
Medicare requires that the equipment be returned to the provider as soon as it is no longer needed.
Example:
* you move your permanent residence out of the provider's normal delivery area
* you get the equipment from another provider
* the patient's condition does not require the equipment
* the patient goes in to the hospital
If the equipment is rented , then the equipment has a monthly renewal date and must be returned (or arranged to be picked up) usually two days prior to the renewal date to avoid
any additional charges. If the provider is coming to pick up the equipment, you should them at least two days prior to the renewal date to have it picked up.
NOTE:
Items that are not rented are: commode, walker, cane, etc. If you are not sure whether your product is rented, call your provider.
If the equipment is an Oxygen Concentrator , then the provider must have a prescription (to discontinue the use of the oxygen) before they can pick it up (since it is a prescribed drug).
NOTE:
Any invoices that are still outstanding for months that the product was being used is still the patient's responsibility (even if the invoice comes much later).
What is a deductible? Why do I get a bill (for my deductible) if my coinsurance
normally pays for the coinsurance payment?
The deductible is the amount of co-payment you are required to pay before Medicare (or any insurance carrier) will begin paying any benefits. The deductible is usually set to zero
at the beginning of every calendar year. However, if you don't have any claims until later in the year, you should expect to receive a deductible bill for the first claim(s) submitted to
Medicare for that calendar year. Your particular secondary insurance plan may not cover the Medicare deductible and therefore is your responsibility to pay the provider.
NOTE:
Medicare will NOT allow a provider to waive a deductible bill.
What do I do if my Doctor has not signed the Certificate of Medical Necessity?
If you have paid for a product (because the provider did not take assignment) and the
doctor has not (but should) filled out the CMN, then you should get another copy from the provider and make an appointment to deliver the CMN to the doctor (or staff) and wait
while they fill it out (or tell them you will be back tomorrow to pick it up).
NOTE: When getting the CMN filled out it is permissible to have a doctor's staff member
fill out the CMN, but the Doctor must review and sign it.
Can an invoice be paid with a credit card?
Yes, ask your provider if they accept credit card payments, or look on their information packet (or any paperwork from them) that you received.
Why do I get a bill if my co-insurance covers the product?
Do you have New Jersey Blue Cross (Horizon) or Federal Blue Cross and Blue Shield? If
so, they will only pay the patient (not the provider) for the product/service. When you receive an invoice from the provider, match it up with the Explanation of Medical Benefits
(EOMB) from your insurance carrier. Your provider can be paid with a check from you or your may sign the insurance carrier's check and write "Pay to the order of Your Provider" and mail it to them.
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