Copyright © 2008 Delmar Learning. All rights reserved. Chapter 14 Medicare.

Copyright © 2008 Delmar Learning. All rights reserved.

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 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 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 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


• 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


• Coordinate patient care, using networks and referrals– Can help with overall care management and

result in cost savings


18


• 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


• 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


• Publication of an annual, regional PAR directory made available to all Medicare patients

• Faster processing of assigned claims


32


• 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


• 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


• 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


• 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


• 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


• 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

Copyright © 2008 Delmar Learning. All rights reserved. Chapter 14 Medicare.

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