Medicare

1. Medicare OT 232 Chapter 10 OT 232 Chapter 10

2. Medicare • Established?! • 1965 • Managed by?! • CMS under… • DHHS • Eligible beneficiaries • 65+ • Disabled adults • Individuals disabled before 18 • Spouses of entitled individuals • Retired federal employees and their spouses • Individuals with end-stage renal disease OT 232 Chapter 10

3. Medicare Part A • Hospital Insurance • Hospital care • Skilled nursing facility care • Home health care • Hospice care • Automatic enrollment • No premium if eligible, but may require deductibles or copays • Table 10.1, page 338 OT 232 Chapter 10

4. Medicare Part B • Supplementary Medical Insurance • Helps with • Physician services • Outpatient hospital • Medical equipment • Voluntary program, coverage is NOT automatic • Premium involved, as well as deductible and coinsurance • See page 342 OT 232 Chapter 10

5. Medicare Part C • “Advantage” • Must be enrolled in Part B • More choices, better benefits, lower costs OT 232 Chapter 10

6. Medicare Part D • Prescription Drug Coverage • Optional • Requires monthly premiums • Two options • Drugs only • Drugs and medical coverage OT 232 Chapter 10

7. Medicare Coverage & Benefits • Medicare card • Provided by SS • HICN • Medicare health insurance claim number • 9 digits with a suffix • Figure 10.1, page 340 OT 232 Chapter 10

8. Medicare Claim Processing • Federal gov’t does not pay Medicare claims directly!! • Hires contractors to process • Fiscal intermediaries • Process claims from hospitals • Carriers • Process claims from physicians • Medical Administrative Contractors (MACs) • Handle claims for Parts A and B • Handle claims based on location OT 232 Chapter 10

9. Medical & Other Services • Preventive Services • If covered, may still be subject to deductible • ONE routine physical exam, called the IPPE • Initial Preventive Physical Exam • Done within 6 months of enrolling in Plan B • Screening vs. Diagnostic Services • Screenings – no symptoms • Diagnostic – has been diagnosed with a condition or has a high probability for it OT 232 Chapter 10

10. Excluded Services • Determined by federal legislation • Not covered under any circumstance vs. not medically necessary • ‘Not medically necessary’ is not normally covered unless certain conditions are met • Still must be essential and not experimental or elective OT 232 Chapter 10

11. Medicare Participating Providers • Optional for providers to participate in Medicare • Once they do, must • accept Medicare’s allowed charge for services • submit claims on behalf of patients • receive payments directly from Medicare OT 232 Chapter 10

12. Incentives • 5% higher fees than for nonPAR • MACs help with claims involving supplementary insurance • Providers in areas with shortages of providers are eligible for 10% bonus OT 232 Chapter 10

13. Payments • Advance Beneficiary Notice of Noncoverage • Used when provider needs authorization to perform a service that won’t be covered by Medicare, and so will be billed to the patient • Helps beneficiaries make decisions about services that might have to be paid out-of-pocket • May be used for excluded services • Modifiers • -GZ – no ABN on file, service is expected to be denied • Cannot bill patient • Emergency • -GA - ABM on file, service is expected to be denied • Can bill patient • -GY – service never covered, ABN not required • Patient is responsible OT 232 Chapter 10

14. PQRI • Physician Quality Reporting Initiative • Quality reporting program done by physicians • Optional • Bonus of 1.5% for participating • Goal? Determine • best practices • define measures • Support improvement • improve systems OT 232 Chapter 10