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MEDICARE

MEDICARE. OBJECTIVES. Identify eligibility requirements for Medicare. Describe differences between part A and part B of Medicare Identify differences between a participating and non participating providers Learn what is primary and secondary payer. INTRODUCTION.

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MEDICARE

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  1. MEDICARE

  2. OBJECTIVES • Identify eligibility requirements for Medicare. • Describe differences between part A and part B of Medicare • Identify differences between a participating and non participating providers • Learn what is primary and secondary payer

  3. INTRODUCTION • MEDICARE is a federal insurance program created in 1965. • It is managed by the Centers for Medicare and Medicaid services CMS

  4. FOUR PARTS OF MEDICARE • Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care. • Medical insurance (Part B) helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance. • Medicare Advantage (Part C) plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C. • Prescription drug coverage (Part D) helps pay for medications doctors prescribe for treatment.

  5. ELIGIBILITY • Age 65 and older, eligible for SS benefits, railroad retiree, or civil service retirement • Disabled and who have received SS disability insurance SSDI for 2 years • Diagnosed with ESRD • Kidney donors – related expenses

  6. ELIGIBILITY • When one becomes eligible he/she is automatically signed for Medicare Part A • All individuals eligible for part A may choose to apply for part B by paying monthly premium • Parts C and D also will require additional premium

  7. PARTICIPATING PROVIDERS • Health care providers may choose to participate or not in Medicare Part B. • If the physician elects to participate he/she signs contract with Medicare. • The contract states that the PAR agrees to accept Medicare approved payment rate for services rendered • Medicare usually pays 80% of UCR • As a PAR, the physician can not balance – bill the patient • PAR bill max 20% of covered services

  8. PAR PROVIDERS • Must accept all Medicare beneficiary and must not discriminate against Medicare beneficiary. • Can withdraw from services only after properly inform their patients.

  9. NONPARTICIPATING PROVIDERS • A nonparticipating provider is a doctor who does not sign a contract with Medicare • He/she can accept Medicare patients on a claim to claim basis • Non par provider may charge max 15% above PAR • Non par physician may collect the difference from the patient.

  10. MEDICARE CLAIM • The CMS 1500 is used for all Medicare claims. • The claim filling deadline is December 31 of the year following date of service. • All PAR providers are required to have UPIN which appears on all claims

  11. MEDICARE AS PRIMARY PAYER • Medicare is the primary payer if one is eligible for both Medicare and Medicaid. • Medicare is also primary payer when: • The individual is eligible for TRICARE / CHAMPVA • The individual is eligible for an employer sponsored insurance plan but has decline it.

  12. MEDICARE INSURANCE CARD

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