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Chapter 14

Chapter 14. Medicare. Introduction. Medicare is the largest medical program in the United States. Medicare Is a Two-Part Program. Medicare Part A: Reimburses institutional providers for inpatient, hospice, and some home health services. Medicare Is a Two-Part Program. Medicare Part B:

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Chapter 14

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  1. Chapter 14 Medicare

  2. Introduction • Medicare is the largest medical program in the United States

  3. Medicare Is a Two-Part Program • Medicare Part A: • Reimburses institutional providers for inpatient, hospice, and some home health services

  4. Medicare Is a Two-Part Program • Medicare Part B: • Reimburses institutional providers for outpatient services and physicians for inpatient and office services

  5. Medicare Program Includes • Medicare Hospital Insurance: • Inpatient hospital critical care access • Skilled nursing facility • Hospice care • Some home health care

  6. Medicare Program Includes • Medicare Medical Insurance: • Pays for doctors’ services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A

  7. Medicare Program Includes • Medicare Advantage: • Formerly called Medicare+Choice • Includes managed care and private fee-for-service plans that provided contracted care to Medicare patients • Medicare Advantage is an alternative to the original Medicare plan reimbursed under Medicare Part A

  8. Medicare Program Includes • Medicare Prescription Drug: • Adds prescription drug coverage to the original Medicare Plan, some Medicare Cost, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

  9. Medicare Eligibility • Individuals or their spouse to have worked at least 10 years in Medicare-covered employment. • Individuals to be a minimum age of 65 years old. • Individuals to be a citizen or permanent resident of the United States.

  10. Medicare Part A 65 Years or Older • Receiving retirement from SS or RRB • Not receiving benefits but are eligible • Had Medicare-covered government employment

  11. Medicare Part A Under Age 65 • Have received Social Security or RRB disability for 24 months • Have end-stage renal disease

  12. Hospitalizations • Medicare pays only a portion of a patient’s acute care and CAH inpatient hospital expenses • Patient’s out-of-pocket expenses are calculated on a benefit-period basis

  13. Medicare Part B • Medicare Part B • Helps pay for physician services • Outpatient hospital care • Some physical and occupational therapy • Some home care

  14. Medicare Part C • Is managed by private companies but are health plans that are approved by Medicare

  15. Medicare Advantage Plans • Require referrals to see specialists • Offer lower premiums or copayments and deductibles than the original Medicare Plan

  16. Medicare Advantage Plans • Have networks • Patients may have to see doctors who belong to the plan or go to certain hospitals to get covered services • Offer extra benefits, such as prescription drug coverage

  17. Medicare Advantage Plans • Coordinate patient care, using networks and referrals • Can help with overall care management and result in cost savings

  18. Medicare Advantage Plans • Medicare patients have the option of enrolling in one of these plans: • Health Maintenance Organization (HMO) • Medicare Medical Savings Account Plan • Medicare Special Needs Plan

  19. Medicare Advantage Plans • Preferred Provider Organization (PPO) • Private fee-for-service plan (PFFS)

  20. Medicare Special Needs Plans • Covers Medicare A and B • For individuals who have chronic illnesses • Managing multiple diseases • Who can benefit the most from special care

  21. May Limit Certain Individuals • Those who are eligible for both Medicare and Medicaid • Those who have certain chronic or disabling conditions • Those who reside in certain institutions

  22. Medicare D • Offers prescription drug coverage to all Medicare patients • May help lower the drug costs and help protect against higher costs in the future

  23. MEDIGAP • Pays for services that Medicare does not pay for

  24. Other Medicare Health Plans • Medicare Cost Plans • Demonstration/Pilot Program • Programs of all-inclusive care for the elderly (PACE)

  25. Medicare Cost Plan • Is a type of HMO • Works much in the same way that Medicare Advantage Plan does

  26. Demonstration/Pilot Program • A special Project that tests improvements in Medicare coverage, payment, and quality of care.

  27. PACE • Combine medical, social, and long-term care services for frail people who live and receive health care in the community

  28. Eligibility for PACE • 55 years old, or older • Resident of the service area covered by the PACE program • Able to live safely in the community • Certified as eligible for nursing home care by the appropriate state agency

  29. Participating Providers • Medicare has an agreement with participating providers to accept assignments on all Medicare claims

  30. The Agreements Include • Direct payment of all claims • Five percent higher fee schedule than for nonparticipating providers • Bonuses provided to Medicare administrative contractors for recruitment and enrollment of PARs

  31. The Agreements Include • Publication of an annual, regional PAR directory made available to all Medicare patients • Faster processing of assigned claims

  32. The Agreements Include • A special message printed on all unassigned Medicare Summary Notice forms mailed to patients • Reminds them of the reduction in out-of-pocket expenses if they use PARs and stating how much they would save with PARs

  33. The Agreements Include • Hospital referrals for outpatient care that provide the patient with the name and full address of at least one PAR provider each time the hospital provides a referral for care.

  34. Nonparticipating Providers • Nonparticipating providers may chose claim-by-claim assignments, but there are some restrictions • NonPARs must file all Medicare claims • Balance billing of the patient by a non-PAR is forbidden

  35. Nonparticipating Providers • Fees are restricted to not more then the “limiting charge” on nonassigned claims • Collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim

  36. Nonparticipating Providers • Patients must sign a surgical disclosure notice for all nonassigned surgical fees over $500 • NonPARs must accept assignment on clinical laboratory charges

  37. Privacy Act • Privacy Act of 1974 • Does not allow the Medicare administrative contractor to reveal the status of any unassigned claim other than the date the claim was received by the MAC

  38. Privacy Act • Date the claim was paid, denied, or suspended • General reason the claim was suspended

  39. Surgical Disclosure Notice • Elective surgery is defined as a surgery that: • Can be scheduled in advance • Is not an emergency • If delayed, would not result in death or permanent impairment of health

  40. Private Contracting • “Under the Balanced Budget Act of 1997, physicians were provided the option of withdrawing from Medicare and entering into private contracts with their Medicare patients.”

  41. Under a Private Contract • No medicare payment will be made for services or procedures provided to a patient. • Other insurance plans may not pay for services or procedures rendered.

  42. Under a Private Contract • Medicare managed care plans will not pay for services rendered under a private contract. • No claim is to be submitted to Medicare • Medicare will not pay if a claim is submitted

  43. Under a Private Contract • Supplemental insurance will not pay for services or procedures rendered • Patient is required to pay whatever the physician/practitioner charges • There is no limit on what the physician can charge for Medicare approved services

  44. Medicare Summary Notice • Is a monthly statement that is easy to read that clearly lists health insurance claims information

  45. Claims Instructions • The law says that all Medicare claims must be filed using optical scanning guidelines.

  46. Medicare and Medigap Claims • Changes must be made to the Medicare main claim when: • Health care provider is a Medicare PAR • Patient has a Medigap policy in addition to Medicare • Patient has signed an Authorization for Release of Medigap Benefits

  47. Medicare-Medicaid Crossover • A Medicare-Medicaid crossover plan provides both Medicare and Medicaid coverage to certain eligible beneficiaries

  48. Medicare asSecondary Payer Claims • Medicare Secondary Payer (MSP) program • Organizes benefits between Medicare and additional payers to determine if an additional insurance plan is primary.

  49. Medicare as Secondary Payer Claims • Contractors uses some of the following to identify insurance primary to Medicare • Initial Enrollment Questionnaire (IEQ) • IRS/SSA/CMS/ Data Match • MSP claims Investigation • Voluntary MSP Data Match Agreements

  50. Roster Billing • Process to enable Medicare beneficiaries to partake in mass pneumococcal pneumonia virus and influenza virus vaccination programs • Offered by community health clinics and other entities that bill Medicare

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