Dear Marci,

I went to the doctor last month and now owe more than I thought I would. I called the office and learned that they charged me a facility fee. What is this?

-Roman (Baton Rouge, LA)

Dear Roman,

You may owe a facility fee when you go to a hospital-owned outpatient clinic. In other words, when you see a doctor at a facility that is owned by a hospital, rather than owned by the doctor. These facility fees help the hospital maintain the clinic by offsetting operational costs.

If your doctor’s office charges you a facility fee, it will be in addition to the cost of your medical care. Your doctor’s office may call it something like a “room charge.” Facility fees can range a lot in cost; the fee could be $15 or $150.

Under Original Medicare, facility fees are a covered service, and you are responsible for 20% of the cost of the fee. Medicare Advantage Plans must also cover facility fees, but there is no requirement as to how much of the fees the plan must cover. Because of this, your copays could be high. If your Medicare Advantage Plan denies coverage for the facility fee, you should appeal on the basis that Medicare Advantage Plans must cover the same services covered by Original Medicare.

Hospital-owned outpatient practices must notify you that you could potentially be charged for use of the facilities. If they don’t, you should file a grievance with your plan and a complaint with Medicare. You may also consider switching to a different provider in the future to avoid these costs.

I hope this helps!

-Marci

Dear Marci,

I recently enrolled in Original Medicare. I know that with Original Medicare, I can see most any provider. Will my costs be the same regardless of which provider I see? Or is there anything else I should consider to get the best costs for my care?

-Iris (Huntington, NY)

Dear Iris,

If you have Original Medicare, your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of providers, meaning three different relationships a provider can have with Medicare. A provider’s type determines how much you will pay for Part B-covered services.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. These providers are required to submit a bill (also called filing a claim) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem. If you see a participating provider, you are responsible for paying a 20% coinsurance for Medicare-covered services. Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.

Non-participating providers accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for health care services as full payment. Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP).

Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care. The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you. Opt-out providers do not bill Medicare for services you receive. Many psychiatrists opt out of Medicare.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool.

-Marci

Dear Marci,

My Part D premium is increasing a lot in 2024, so I want to use Fall Open Enrollment to sign up for a different Part D plan. How should I choose a new Part D plan?

-Louise (Fort Lauderdale, FL)

Dear Louise,

I’m glad to hear you’re comparing your Medicare coverage options this fall! Research shows that many people with Part D could lower their costs by shopping among plans each year. There could be another Part D plan in your area that covers the drugs you take with fewer restrictions or with lower costs, so it’s great that you are trying to compare plans.

I would recommend using Plan Finder to compare Part D plans. Medicare Plan Finder is an online tool at www.medicare.gov that can be used to compare stand-alone Part D plans or Medicare Advantage Plans. Plan Finder provides information about costs, drug coverage, and the star rating of the plan.

To use Plan Finder, follow these steps:

Go to www.medicare.gov and click on the button that says, “Find Plans Now.”
You can do a general search on the right side of the page, under the title “Continue without logging in.” If you wish to save your drugs and pharmacy information, you can log into or create your Medicare account on the left side of the page.
Next, put in your zip code and then choose what kind of plan you are looking for—a Medicare Advantage Plan, a Medicare drug plan, or a Medigap policy.
Then you can enter the drugs you take, choose the pharmacies you use, and indicate whether you are interested in a mail order option.

Plan Finder will display results for plans in your area. Note that a plan may not cover all the drugs you take, but it may cover alternatives. Speak to your provider about whether these alternatives would be appropriate for you. Plan Finder also tells you if the plan has a deductible and how much the monthly premium is.

Initially, the plans will be sorted by “lowest drug + premium costs.” This is the closest estimate to what you may pay out of pocket for your Part D coverage for the year. You can select “Plan Details” to find out more specifics about coverage, including any coverage restrictions that might apply to your drugs.

Before enrolling, it is a good idea to call the plan directly to confirm any information you read on Plan Finder, as information may not be completely up to date. Here is a list of questions you can ask when calling a company about their prescription drug coverage. You can enroll in a plan online, by calling 1-800-MEDICARE (633-4227), or by calling the plan directly.

You can make as many changes as you want between October 15 and December 7, but only the last change you make will take effect on January 1.

Good luck choosing the best Part D plan for your needs!

-Marci

Dear Marci,

I enrolled in Medicare earlier this year. My sister told me that Fall Open Enrollment for Medicare is coming up. What is Fall Open Enrollment, and what do I need to do during this time?

-Abigail (Redding, CA)

Dear Abigail,

Fall Open Enrollment runs from October 15 through December 7 each year. This period is also sometimes called the Annual Election Period. During this time, you can make changes to your health insurance coverage, including adding, dropping, or changing your Medicare coverage. Even if you’re happy with your current health and drug coverage, Fall Open Enrollment is the time to review what you have, compare it with other options, and make sure that your current coverage still meets your needs for the coming year.

You can make as many changes as you need to your Medicare coverage during Fall Open Enrollment. The changes you can make include:

Joining a new Medicare Advantage Plan
Joining a new Part D prescription drug plan
Switching from Original Medicare to a Medicare Advantage Plan
Switching from a Medicare Advantage Plan to Original Medicare (with or without a Part D plan)

Regardless of how you receive your Medicare coverage, you should consider:
Your access to health care providers you want to see
Your access to preferred pharmacies
Your access to benefits and services you need
The total costs for insurance premiums, deductibles, and cost-sharing amounts

If you have Original Medicare, visit www.medicare.gov or read the 2024 Medicare & You handbook to learn about Medicare’s benefits for the upcoming year. You should review any increases to Original Medicare premiums, deductibles, and coinsurance charges.

If you have a Medicare Advantage Plan or a stand-alone Part D plan, read your plan’s Annual Notice of Change (ANOC) and/or Evidence of Coverage (EOC). Review these notices for any changes in:
The plan’s costs
The plan’s benefits and coverage rules
The plan’s formulary (list of drugs your plan covers)

Make sure that your drugs will still be covered next year and that your providers and pharmacies are still in the plan’s network. If you are unhappy with any of your plan’s changes, you can enroll in a new plan. If you want assistance reviewing your options, contact your State Health Insurance Assistance Program (SHIP) for individualized counseling.

Even if you are happy with your current Medicare coverage, consider other Medicare health and drug plan options in your area. For example, even if you do not plan to change your Medicare Advantage or Part D plan, you should check to see if there’s another plan in your area that will offer you better health and/or drug coverage at a more affordable price. Research shows that people with Medicare prescription drug coverage could lower their costs by shopping among plans each year. There could be another Part D plan in your area that covers the drugs you take with fewer restrictions and/or lower prices.

-Marci

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