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Medicare Supplemental Insurance
Medicare Definitions

Actual Charge: The amount a physician or supplier actually bills for a particular medical service or supply.
Approved Amount: The amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare. It may be less than the actual charge for physician services. The approved amount is taken from a national fee schedule that assigns a dollar value to all physician services covered by Medicare.

Assignment: An arrangement whereby a physician or medical supplier agrees to accept the Medicare-approved amount as the total charge for services and supplies covered under Part B. Medicare usually pays 80% of the approved amount directly to the provider after the beneficiary meets the annual Part B deductible of $100. The beneficiary pays the other 20%.

Benefit Period: A benefit period begins the first day you receive a Medicare-covered service in a qualified hospital. It ends when you have been out of a hospital or other facility that primarily provides skilled nursing or rehabilitation services for 60 days in a row. It also ends if you remain in a facility (other than a hospital) that primarily provides skilled nursing or rehabilitation services but does not receive any skilled care there for 60 days in a row.

Co-Insurance: The portion or percentage of Medicare's approved amount for covered services that beneficiary is responsible for paying.

Deductible: The amount of expense a beneficiary must incur before Medicare begins payment for covered services.

Excess Charge: The difference between the Medicare approved amount for a service or supply and the actual charge, if the actual charge is more than the approved amount.

Limiting Charge: The maximum amount a physician may charge for a covered service if the physician does not accept assignment of the Medicare claim. Limiting charge information appears on Medicare's Explanation of Medicare Benefits (EOMB) form.

Participating Physician & Supplier: A physician or supplier who agrees to accept assignment on all Medicare claims.


 
   
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