By CWO4 Lewis Tolleson, USCG-Ret., Director; Lt. Col. William A. Pierce, USA-Ret.; and Capt. Bud Schneeweis, USCG-Ret.

Medicare

What is "assignment" in Medicare Part B, and why is it important?

Assignment is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies. Doctors and suppliers who accept assignment allow the Medicare-approved amount as payment in full for Part B services and supplies. TRICARE For Life (TFL) will pay copayments and deductible amounts.

If assignment is not accepted, costs are often higher, which means you may pay more. In addition, you may have to pay the entire bill at the time of service. Medicare and TFL then will send you their share of the bill.

There is a limit to the amount your doctors and providers who don't accept assignment can charge you for a covered service. The limiting charge, or Medicare Maximum Allowable Charge (MMAC), is 15 percent over Medicare's approved amount and applies only to certain services - not to supplies or equipment. TFL will pay up to the MMAC.

Do my doctors have to tell me beforehand if they don't accept assignment?

Providers are not obligated to inform each patient of their assignment status before providing services. If you are concerned about your out-of-pocket responsibility, ask the pro-vider before receiving services.

How does Medicare decide if a service is covered?

Benefits available to Medicare beneficiaries are called "covered" services. First, your doctor must decide that a particular service or procedure is medically necessary. In some cases, even if your doctor prescribes an item or service, Medicare may not pay for it. Certain items are specifically excluded from coverage, while others are subject to interpretation.

Requests for Medicare coverage are evaluated according to prescribed procedures. The first action is a determination that the law allows it to be covered. After that, Medicare looks carefully at the scientific evidence to support coverage of the item or service for all beneficiaries when their doctors decide the service is needed.

If a beneficiary is 65 and receiving Medicare benefits, does his or her under-65 spouse receive them too?

Generally not. The minimum age for Medicare eligibility is 65. But, if you've been getting Social Security disability benefits for 24 months you can receive Medicare at any age.

How is the Medicare Part B deductible applied?

It is applied based on the date the claim is processed by Medicare, not the actual date you got the service. However, certain services won't be applied to your deductible. TFL pays the annual Medicare deductible only for TRICARE-approved services. If a chiropractic service (covered by Medicare but not TRICARE) is your first service of the year, TFL will not pay the deductible for that service.

Providers may ask you to pay a portion of your deductible at the time you get the service or bill you after finding out what amount was approved by Medicare. However, providers can't ask you to pay more than the amount approved for the service(s) you received that day. In addition, providers should show the amount you already paid on the claim they submit to Medicare.

Does the original Medicare plan pay for care in a nursing home?

Usually, no. Most nursing home care is custodial care (help with bathing, dressing, using a bathroom, and eating), which Medicare does not cover. Medicare Part A covers only skilled care given in a certified skilled nursing facility. You must meet certain conditions, and coverage is limited.

If you have limited income and resources, Medicaid might help cover nursing home costs.