Providing additional facts on Medicare

Patricia Hafermann • Benefit Specialist

Benefit Period: Under Medicare Part A, a period of hospitalization is called a benefit period. A benefit period begins the day you are admitted to a hospital. It ends when you have been out of the hospital or a nursing facility for 60 consecutive days. If you are re-admitted within that 60 days, you are still in the same benefit period and would not pay another deductible. If you are admitted to a hospital after that benefit period ends, an entirely new benefit period begins and a new deductible must be paid. If you do not automatically get premium-free Medicare Part A, you may be able to buy it. For more information, visit or call Social Security at 1-800-772-1213.

Assignment in Original Medicare: sometimes a doctor or other provider accepts “assignment.” This means that the doctor or provider is paid directly by Medicare and accepts the “Medicare-approved” amount as full payment.

Limiting Charge: A doctor, provider, or supplier who does not accept assignment: can charge more than the Medicare approved amount. In this case, you are responsible not only for the usual 20 percent of the approved charge for the service, but also for 100 percent of the excess charges, which is the portion of the fee that exceeds the approved amount. Medicare limits the amount a doctor or provider who does not accept assignment may charge you for Medicare-covered services. Under federal law, your doctor may not charge more than this limiting charge. The limiting charge is 15 percent over Medicare’s approved amount.

Other Charge Limits: Physicians who do not accept assignment for elective surgery are required to give you a written estimate of your costs before the surgery if the total charge will be $500 or more. If you are not given an estimate, you are entitled to a refund of any amount you paid in excess of the Medicare-approved amount. If you are given a written notice and have signed an agreement to pay, you are held liable for the costs.

Private Contract: Some doctors do not accept Medicare payments. If you want to get care from a doctor who does not accept Medicare payment, you may be asked to sign a private contract.

A private contract is a written agreement between you and a doctor or other health care provider who has decided not to give services through the Medicare program. The private contract only applies to the services you get from the doctor who asked you to sign it. You cannot be asked to sign a private contract in an emergency situation or when you get urgently needed care.

Note: You still have the right to see other Medicare doctors for services. You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider. SHIP is a free counseling service for Medicare beneficiaries that provides information regarding Medicare and Medigap insurance policies.

State Health Insurance Program: SHIP’s Medigap Helpline (1-800-242-1060) can help you with questions about health insurance, primarily Medicare supplements, longterm care insurance, and other health care plans available to Medicare beneficiaries. The Medigap Helpline is provided by the State of Wisconsin Board on Aging and Long-Term Care at no cost to you. There is no connection with any insurance company.

Out-of-Pocket Expenses: Out-of-pocket refers to costs, bills, fees, or expenses you will have to pay yourself. Out-of-pocket expenses occur when you received a service not covered by Medicare, when you receive a service only partially covered by Medicare, or when you choose a provider whose fees exceed Medicare’s approved charges. You will also have to pay out-of-pocket expenses to cover the deductible and copayments. The amount of these expenses you pay out-of pocket depends on whether you have insurance that supplements your Medicare coverage.

If you have any additional questions, you may call Pat Hafermann, Elderly Benefits Specialist with the Aging and Disability Resource Center at (920) 467-4076.

Sources: Wisconsin Office of the Commissioner of Insurance

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