Q: I am a 69-year-old federal retiree covered by a Blue Cross/Blue Shield Standard Option 105 health plan as well as Medicare Part A. I recently spoke with Blue Cross about reimbursement levels for doctor care when I received a bill from my internist for $400 and Blue Cross paid $100. According to Blue Cross, I was responsible for the remaining $300 because Congress had passed rules (they may have meant that the Office of Personnel Management generated a rule, I am not sure) that limited the amount they could reimburse Medicare patients for a given procedure. When I checked with OPM, they said that the doctor could only charge me 115 percent of the Medicare level.
I could not get a clear answer from Blue Cross or OPM: Does this mean that any doctor I go to cannot charge me more than 115 percent of the base Medicare amount? What about doctors who do not participate in Medicare? When I asked Medicare, they said that a doctor can charge you more than the 115 percent if you sign a special contract agreeing to pay his bill in full; however, this measure is related to Medicare Part B, not Blue Cross. Before I argue with my internist about the invoice, I would like to know what the law says regarding federal retirees.
A: The rules governing in-patient hospital charges, physician charges, and Federal Employees Health Benefit benefit payments are found in the Code of Federal Regulations 5 CFR 890, Subpart I, beginning at Section 890.901. That document is available here.