Medicare & Medicare/Medi-Cal Information

Medicare Information

In general, Medicare pays for about 79% of the "allowable amount" for psychotherapy sessions.  The approximately 21% patient responsibility/coinsurance portion is often covered by coinsurances such as AARP/UnitedHealthCare, Perscare, Blue Cross Medi-Cal, etc.  Some coinsurances also pay your yearly deductible ($183 2018).

Medicare providers have agreed to "accept assignment" for services covered by Medicare.  This means they cannot bill you over and above the amount assigned by Medicare for specific services.  

Important Medicare/Medi-Cal Information

"You should be aware that certain billing prohibitions apply to dual eligible individuals whom you serve. Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of the Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMB* individuals for all Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments you receive for furnishing services to a QMB individual are considered payment in full. You are subject to sanctions if you bill a QMB individual for amounts above the sum total of all Medicare and Medicaid payments (even when Medicaid pays nothing). For more information on prohibited billing of QMB individuals, visit CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1128.pdf and SSA.gov/OP_Home/ssact/title19/1902.htm. In addition, under Section 1848(g)(3)(A) of the Act, all Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries. Assignment means that the Medicare-allowed amount (Physician Fee Schedule amount) constitutes payment in full for all Part B-covered services provided to beneficiaries."

*FYI: QMB means Dual Eligible Medicare/Medi-Cal

**In addition, providers are required by law to bill Medicare for you, even when they are not a Medicare provider.


 
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