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Financing Health Care for Older Adults: A Focus on Medicare Dale K. Hursh, MD Dale K. Hursh, MD January 23, 2008 January 23, 2008.

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Presentation on theme: "Financing Health Care for Older Adults: A Focus on Medicare Dale K. Hursh, MD Dale K. Hursh, MD January 23, 2008 January 23, 2008."— Presentation transcript:

1 Financing Health Care for Older Adults: A Focus on Medicare Dale K. Hursh, MD Dale K. Hursh, MD January 23, 2008 January 23, 2008

2 Learning Objectives Appreciate how Medicare fits in the overall system of health care financing for older adults Appreciate how Medicare fits in the overall system of health care financing for older adults Learn how Medicare developed and changed over time Learn how Medicare developed and changed over time Learn details of coverage and costs of Medicare’s different parts Learn details of coverage and costs of Medicare’s different parts Understand how the federal government monitors and protects the Medicare Trust Fund Understand how the federal government monitors and protects the Medicare Trust Fund

3 National Health Expenditures 2006 Total: $2.1 trillion Total: $2.1 trillion $7,026 per person $7,026 per person 16% of nation’s GDP 16% of nation’s GDP A 6.7% increase from 2005 A 6.7% increase from 2005

4 Health Care Spending 2006 Hospital Hospital 7% growth in 2006 to $648.2 billion 7% growth in 2006 to $648.2 billion Deceleration in growth from 8.2% in 2002 Deceleration in growth from 8.2% in 2002 Physician Services Physician Services 5.9% growth in 2006 to $447.6 billion 5.9% growth in 2006 to $447.6 billion Slowest rate of growth since 1999 Slowest rate of growth since 1999 Home Health Home Health 9.9% growth in 2006 to $52.7 billion 9.9% growth in 2006 to $52.7 billion Deceleration in growth from 12.3% in 2005 Deceleration in growth from 12.3% in 2005 Fastest growing component of personal health care spending Fastest growing component of personal health care spending

5 Health Care Spending 2006, cont’d Nursing Homes Nursing Homes 3.5% growth in 2006 to $124.9 billion 3.5% growth in 2006 to $124.9 billion Deceleration in growth from 4.9% in 2005 Deceleration in growth from 4.9% in 2005 Slowest rate of growth since 1999 Slowest rate of growth since 1999 Prescription Drugs Prescription Drugs 8.5% growth in 2006 to $216.7 billion 8.5% growth in 2006 to $216.7 billion Growth accelerated for first time in 6 years from low of 5.8% in 2005 Growth accelerated for first time in 6 years from low of 5.8% in 2005 DME DME 2.3% growth in 2006 to $23.7 billion 2.3% growth in 2006 to $23.7 billion Growth accelerated in 2006 Growth accelerated in 2006

6 2006 Health Spending by Major Sources of Funds Medicare Medicare 18.7% total spending growth to $401.3 billion 18.7% total spending growth to $401.3 billion Acceleration in growth from 9.3% in 2005 Acceleration in growth from 9.3% in 2005 Medicaid Medicaid Spending fell by 0.9% to $308.6 billion Spending fell by 0.9% to $308.6 billion First time total Medicaid spending declined since inception of the program First time total Medicaid spending declined since inception of the program

7 2006 Health Spending by Major Sources of Funds, cont’d Private Health Insurance Private Health Insurance 5.5% growth in private health insurance premiums in 2006 to $723.4 billion (slowest rate of growth since 1997) 5.5% growth in private health insurance premiums in 2006 to $723.4 billion (slowest rate of growth since 1997) 6.0% growth in benefit payments in 2006 to $634.6 billion (decline in growth from 2005) 6.0% growth in benefit payments in 2006 to $634.6 billion (decline in growth from 2005) Out-of-Pocket Out-of-Pocket 3.8% growth in spending to $256.5 billion 3.8% growth in spending to $256.5 billion Deceleration in growth from 2005 Deceleration in growth from 2005 Accounted for 12% of national health spending in 2006 Accounted for 12% of national health spending in 2006

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10 43.2 million people covered by Medicare 43.2 million people covered by Medicare 36.3 million aged 65 and older 36.3 million aged 65 and older 7.0 million disabled 7.0 million disabled Total benefits paid were $402 billion Total benefits paid were $402 billion Medicare in 2006

11 Major Sources of Health Care Funding for Elderly in the U.S. Medicare (Federal Government) Medicare (Federal Government) Medicaid (Federal and State Government) Medicaid (Federal and State Government) Other Federal Programs Other Federal Programs Veterans Health Administration Veterans Health Administration Older Americans Act Older Americans Act Title XX of the Social Security Act Title XX of the Social Security Act Military Retiree Benefits (TRICARE) Military Retiree Benefits (TRICARE) PACE program PACE program Private Insurance Private Insurance Medigap (Medicare Supplement Insurance) Policies Medigap (Medicare Supplement Insurance) Policies Long-Term Care Insurance Long-Term Care Insurance Out-of-Pocket Out-of-Pocket

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14 History of Social Security and the Origins of Medicare

15 Development of Social Security The foundation of economic security for much of human history was people living and working on farms in extended families The foundation of economic security for much of human history was people living and working on farms in extended families Industrial Revolution brought change Industrial Revolution brought change More people became wage-earners working for others More people became wage-earners working for others Less reliance on family and farming Less reliance on family and farming Relocation from rural communities to cities Relocation from rural communities to cities

16 Development of Social Security, cont’d The idea of having a program of economic security in a modern, industrialized world developed in Europe in late 19 th century The idea of having a program of economic security in a modern, industrialized world developed in Europe in late 19 th century U.S. 1930s: economic upheaval brought on by the Great Depression played a role in the development of the Social Security program in this country U.S. 1930s: economic upheaval brought on by the Great Depression played a role in the development of the Social Security program in this country

17 Social Security Act Signed into law by FDR on August 14, 1935 Signed into law by FDR on August 14, 1935 Created a social insurance program designed to pay retired workers age 65 or older a continuing income after retirement Created a social insurance program designed to pay retired workers age 65 or older a continuing income after retirement Establishment of the Social Security Board Establishment of the Social Security Board

18 Franklin D. Roosevelt “We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age. This law, too, represents a cornerstone in a structure which is being built, but is by no means complete…. It is…a law that will take care of human needs and at the same time provide for the United States an economic structure of vastly greater soundness.” August 14, 1935

19 1939 Amendments Two new benefit categories added Two new benefit categories added Dependents benefits (spouse and minor children of the worker) Dependents benefits (spouse and minor children of the worker) Survivors benefits (paid to family in event of premature death of worker) Survivors benefits (paid to family in event of premature death of worker) Transformed Social Security from a retirement program for individuals into a family-based economic security program Transformed Social Security from a retirement program for individuals into a family-based economic security program

20 Additions and Changes to the Social Security Program 1950 Amendments 1950 Amendments Raised benefits Raised benefits Legislated Cost-of-Living Adjustments (COLAS) Legislated Cost-of-Living Adjustments (COLAS) The Social Security Amendments of 1954 The Social Security Amendments of 1954 Initiated a disability insurance program Initiated a disability insurance program Amendments of 1961 Amendments of 1961 Age at which men first eligible for retirement benefits was lowered to 62 Age at which men first eligible for retirement benefits was lowered to 62 Social Security Amendments of 1965 Social Security Amendments of 1965 Passage of Medicare and Medicaid Passage of Medicare and Medicaid

21 Medicare Established This legislation provided for health coverage to be extended to Social Security beneficiaries aged 65 or older (eventually extended to those receiving disability benefits as well) This legislation provided for health coverage to be extended to Social Security beneficiaries aged 65 or older (eventually extended to those receiving disability benefits as well) Signed into law on July 30, 1965 by LBJ Signed into law on July 30, 1965 by LBJ Social Security maintained responsibility for Medicare until a 1977 reorganization created HCFA; in 2001, HCFA renamed CMS Social Security maintained responsibility for Medicare until a 1977 reorganization created HCFA; in 2001, HCFA renamed CMS

22 Medicare Bill Signed 1965

23 Medicare A health insurance program for: A health insurance program for: People 65 years of age or older People 65 years of age or older People under age 65 with certain disabilities People under age 65 with certain disabilities People of all ages with ESRD People of all ages with ESRD

24 The Parts of Medicare Part A is hospital insurance Part A is hospital insurance Part B is medical insurance Part B is medical insurance Part C is Medicare Advantage (formerly Medicare + Choice) Part C is Medicare Advantage (formerly Medicare + Choice) Part D is the prescription drug plan Part D is the prescription drug plan

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26 Organizations That Impact Medicare Social Security Administration Social Security Administration OIG OIG Quality Improvement Organizations Quality Improvement Organizations State Health Insurance Assistance Programs State Health Insurance Assistance Programs

27 Recent Laws That Impact Medicare Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Health Insurance Portability and Accountability Act of 1996 Health Insurance Portability and Accountability Act of 1996

28 Medicare Part A: Hospital Insurance Helps cover inpatient care Helps cover inpatient care Hospitals Hospitals Semiprivate room, private room only if medically necessary, meals, general nursing, other hospital services and supplies Semiprivate room, private room only if medically necessary, meals, general nursing, other hospital services and supplies Does not include private duty nursing or TV or phone in room Does not include private duty nursing or TV or phone in room Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime

29 Medicare Part A, cont’d SNF (not custodial or LTC) SNF (not custodial or LTC) After a qualifying three-day hospital stay; must enter SNF within 30 days of leaving hospital After a qualifying three-day hospital stay; must enter SNF within 30 days of leaving hospital Coverage up to 100 days in a benefit period Coverage up to 100 days in a benefit period Benefit period ends with occurrence of break of at least 60 consecutive days since inpatient hospital or SNF care was provided Benefit period ends with occurrence of break of at least 60 consecutive days since inpatient hospital or SNF care was provided No limit to number of benefit periods No limit to number of benefit periods Semiprivate room, meals, skilled nursing and rehab services, medications, and other supplies Semiprivate room, meals, skilled nursing and rehab services, medications, and other supplies

30 Medicare Part A, cont’d Hospice care Hospice care People with terminal illness with 6 months or less life expectancy if the disease runs its normal course People with terminal illness with 6 months or less life expectancy if the disease runs its normal course Coverage includes drugs, medical and support services, grief counseling Coverage includes drugs, medical and support services, grief counseling Coverage of some short-term inpatient stays (pain and symptom management) and for respite care Coverage of some short-term inpatient stays (pain and symptom management) and for respite care

31 Medicare Part A, cont’d Some home health care Some home health care Limited to part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) ordered by a physician Limited to part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) ordered by a physician May also include medical social services, home health aide, DME May also include medical social services, home health aide, DME Patients are required to be "homebound" as a condition of eligibility for these services. Patients are required to be "homebound" as a condition of eligibility for these services.

32 Medicare Part A Costs to Patients in Original Medicare Plan—2008 Monthly premium is not paid for those (or their spouse) who paid Medicare taxes while working Monthly premium is not paid for those (or their spouse) who paid Medicare taxes while working For those not eligible for premium-free Part A, cost of monthly premium is up to $423 For those not eligible for premium-free Part A, cost of monthly premium is up to $423

33 Medicare Part A Costs to Patients in Original Medicare Plan—2008 Hospital Hospital $1,024 deductible and no coinsurance for days of 1–60 each benefit period $1,024 deductible and no coinsurance for days of 1–60 each benefit period $256 per day for days 61 – 90 each benefit period $256 per day for days 61 – 90 each benefit period $512 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over lifetime) $512 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over lifetime) Most individuals do not pay a monthly premium for part A because they or a spouse paid Medicare taxes while working Most individuals do not pay a monthly premium for part A because they or a spouse paid Medicare taxes while working Blood Blood Patient pays for the first three pints of blood, then 20% of Medicare-approved amount for additional pints used (unless the patient or someone else donates blood to replace what is used) Patient pays for the first three pints of blood, then 20% of Medicare-approved amount for additional pints used (unless the patient or someone else donates blood to replace what is used)

34 Medicare Part A Costs to Patients in Original Medicare Plan—2008 SNF Care SNF Care Patient pays $0 for first 20 days each benefit period Patient pays $0 for first 20 days each benefit period For days 21 – 100, patient pays $128 per day For days 21 – 100, patient pays $128 per day Patient pays all costs beyond the 100 th day in the benefit period Patient pays all costs beyond the 100 th day in the benefit period Home Health Care Home Health Care Costs patient $0 for Medicare-approved services Costs patient $0 for Medicare-approved services Patient pays 20% of Medicare-approved amount for DME Patient pays 20% of Medicare-approved amount for DME

35 Medicare Part A Costs to Patients in Original Medicare Plan—2008 Hospice Care Hospice Care Co-payment of up to $5.00 per Rx for outpatient prescription drugs Co-payment of up to $5.00 per Rx for outpatient prescription drugs 5% of Medicare-approved amount for inpatient respite care 5% of Medicare-approved amount for inpatient respite care Generally, room and board not covered (e.g., not covered in nursing facility) Generally, room and board not covered (e.g., not covered in nursing facility)

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37 Medicare Part B: Medical Insurance Helps to cover Helps to cover Medically necessary doctors’ services, outpatient care, and other medical services not covered by Part A Medically necessary doctors’ services, outpatient care, and other medical services not covered by Part A Some preventive services Some preventive services

38 Medicare Part B Covered Services (not all-inclusive list) Ambulance services Ambulance services Ambulatory surgery center fees Ambulatory surgery center fees Blood (outpatient) Blood (outpatient) Chiropractor services (limited) Chiropractor services (limited) Diabetes supplies Diabetes supplies Diagnostic tests Diagnostic tests DME DME Doctor services Doctor services ER services ER services Eye exams (limited) Eye exams (limited) Hearing and balance exams Home health services Kidney dialysis services and supplies Outpatient mental health care Outpatient PT, OT, ST Medically necessary clinical lab services Outpatient hospital services Prosthetic/orthotic items

39 Medicare Preventive Services—Part B (not all-inclusive list) AAA screening AAA screening One-time “Welcome to Medicare” physical exam One-time “Welcome to Medicare” physical exam Cardiovascular screening Cardiovascular screening Breast cancer screening Breast cancer screening Cardiovascular screenings Cardiovascular screenings Cervical and vaginal cancer screening Cervical and vaginal cancer screening Colorectal cancer screenings Colorectal cancer screenings Diabetes screenings Diabetes screenings Diabetes self-management training Diabetes self-management training Prostate cancer screening Prostate cancer screening Immunizations (flu vaccine, pneumonia vaccine, hepatitis B) Immunizations (flu vaccine, pneumonia vaccine, hepatitis B) Bone mass measurements Bone mass measurements Diabetes screening, supplies, and self-management training Diabetes screening, supplies, and self-management training Glaucoma tests Glaucoma tests Medical nutrition therapy services Medical nutrition therapy services Smoking cessation Smoking cessation

40 Medicare Part B Costs to Patients in Original Medicare Plan—2008 Annual deductible of $135 Annual deductible of $135 Monthly premium of $96.40 Monthly premium of $96.40 Premium may be higher depending on income and whether or not individual signed up for Part B when first eligible Premium may be higher depending on income and whether or not individual signed up for Part B when first eligible Pay coinsurance (generally 20% of the Medicare-approved amount) when required Pay coinsurance (generally 20% of the Medicare-approved amount) when required

41 Medicare Part B Services Requiring 20% Coinsurance (not all-inclusive list) Ambulance services Ambulance services Ambulatory surgery center fees Ambulatory surgery center fees Blood (starting with 4 th unit—1 st 3 patient pays) Blood (starting with 4 th unit—1 st 3 patient pays) Chiropractor services Chiropractor services Diabetes supplies Diabetes supplies Doctor services Doctor services DME DME ER services ER services Eye exams Eye exams Hearing and balance exams Hearing and balance exams Kidney dialysis services and supplies Kidney dialysis services and supplies OT, PT, ST OT, PT, ST Outpatient hospital services Outpatient hospital services Prosthetic/orthotic devices Prosthetic/orthotic devices

42 Medicare and “Assignment” Agreement between Medicare beneficiaries, their doctors and suppliers, and Medicare Agreement between Medicare beneficiaries, their doctors and suppliers, and Medicare Individual with Medicare agrees to allow the doctor to request direct payment from Medicare for covered Part B services Individual with Medicare agrees to allow the doctor to request direct payment from Medicare for covered Part B services Doctors agreeing to accept assignment from Medicare cannot try to collect more than the proper Medicare deductibles and co-insurance amounts from the person with Medicare, or their other insurance Doctors agreeing to accept assignment from Medicare cannot try to collect more than the proper Medicare deductibles and co-insurance amounts from the person with Medicare, or their other insurance

43 Medicare Part B Costs to Patients in Original Medicare Plan— % of most outpatient mental health services 50% of most outpatient mental health services Patient pays $0 for Medicare-approved clinical lab services Patient pays $0 for Medicare-approved clinical lab services Patient pays $0 for Medicare-approved home health services Patient pays $0 for Medicare-approved home health services 20% of Medicare-approved amount for DME 20% of Medicare-approved amount for DME Blood Blood Patient pays for first three pints, then 20% of the Medicare-approved amount for additional pints unless someone else donates to replace Patient pays for first three pints, then 20% of the Medicare-approved amount for additional pints unless someone else donates to replace

44 What Is Not Paid For by Medicare Part A or Part B in the Original Medicare Plan Acupuncture Acupuncture Deductibles, coinsurance, co-payments Deductibles, coinsurance, co-payments Dental care and dentures Dental care and dentures Cosmetic surgery Cosmetic surgery Health care when traveling out of the U.S. Health care when traveling out of the U.S. Hearing exams unless ordered by physician Hearing exams unless ordered by physician Hearing aids and hearing exams for the purpose of fitting a hearing aid Hearing aids and hearing exams for the purpose of fitting a hearing aid Custodial care, long-term care in nursing home Custodial care, long-term care in nursing home Orthopedic shoes (with only a few exceptions) Orthopedic shoes (with only a few exceptions) Routine foot care (with only a few exceptions) Routine foot care (with only a few exceptions) Routine eye care and most eyeglasses Routine eye care and most eyeglasses Routine or yearly physical exams Routine or yearly physical exams

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46 Medicare Part C Medicare Advantage plans Medicare Advantage plans Health plan options approved by Medicare and run by private companies Health plan options approved by Medicare and run by private companies Available in most areas of U.S. Available in most areas of U.S. Must be eligible for Medicare A and B to join Must be eligible for Medicare A and B to join Plans include: Plans include: PPO plans PPO plans HMO plans HMO plans PFFS plans PFFS plans Medical Savings Account (MSA) plans Medical Savings Account (MSA) plans Special Needs Plans (SNP) Special Needs Plans (SNP)

47 Medicare Advantage Plans Provide all of a patient’s Part A and Part B benefits Provide all of a patient’s Part A and Part B benefits Must cover at least all of the medically- necessary services that the Original Medicare Plan provides Must cover at least all of the medically- necessary services that the Original Medicare Plan provides May offer extra benefits such as vision, hearing, dental, and health and wellness programs May offer extra benefits such as vision, hearing, dental, and health and wellness programs Most offer prescription drug coverage Most offer prescription drug coverage

48 Medicare Advantage Plans Costs to Patients in 2008 Depends on the type of plan and the specific company Depends on the type of plan and the specific company Monthly part B premium + monthly premium charged by company for the plan (which generally includes Part A and Part B benefits, Medicare prescription drug coverage if offered and extra benefits if offered) Monthly part B premium + monthly premium charged by company for the plan (which generally includes Part A and Part B benefits, Medicare prescription drug coverage if offered and extra benefits if offered)

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50 Medicare Part D Prescription drug benefit plans Prescription drug benefit plans Medicare contracts with private companies to offer coverage Medicare contracts with private companies to offer coverage Anyone with Medicare Part A and/or B can join Anyone with Medicare Part A and/or B can join

51 Medicare D Costs to Patients—2008 Exact costs differ among plans, but include monthly premium, yearly deductible, co-payments and coinsurance, coverage gap Exact costs differ among plans, but include monthly premium, yearly deductible, co-payments and coinsurance, coverage gap CMS estimate of average monthly premium for standard Part D coverage is $25 CMS estimate of average monthly premium for standard Part D coverage is $25

52 Medicare D Costs to Patients— 2008, cont’d Base premium of $27.93 Base premium of $27.93 Initial deductible of $275 Initial deductible of $275 Coinsurance of 25% of remaining costs, up to an initial coverage limit of $2,510 Coinsurance of 25% of remaining costs, up to an initial coverage limit of $2,510 Beneficiary then pays for all costs until an out-of-pocket threshold of $4,050 is reached Beneficiary then pays for all costs until an out-of-pocket threshold of $4,050 is reached

53 $2,510$4,050

54 Medicare Part D: Coverage Gap Patients continue to pay monthly premiums while in the coverage gap Patients continue to pay monthly premiums while in the coverage gap Each state offers at least one plan with gap coverage, but these plans generally charge a higher monthly premium Each state offers at least one plan with gap coverage, but these plans generally charge a higher monthly premium Once patient reaches limit of coverage gap set by plan, they receive “catastrophic coverage” Once patient reaches limit of coverage gap set by plan, they receive “catastrophic coverage”

55 Medicare D Catastrophic Coverage Provides for special prescription drug coverage once patient spends $4,050 in 2008 Provides for special prescription drug coverage once patient spends $4,050 in 2008 Limit may vary depending on the plan Limit may vary depending on the plan After reaching limit, patient pays the greater of 5% coinsurance or a small defined co- payment amount per prescription After reaching limit, patient pays the greater of 5% coinsurance or a small defined co- payment amount per prescription

56 Medigap Policies (Medicare Supplement Insurance) Health insurance policies sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage Health insurance policies sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage Must follow federal and state laws Must follow federal and state laws Not needed and cannot be used if patient is in a Medicare Advantage Plan Not needed and cannot be used if patient is in a Medicare Advantage Plan Generally must have Medicare Part A and Part B Generally must have Medicare Part A and Part B Medigap insurance premium paid in addition to monthly Part B premium Medigap insurance premium paid in addition to monthly Part B premium

57 Payment of Bills in The Original Medicare Plan Part A services (and some Part B services) Part A services (and some Part B services) Provider of service such as a hospital or home health agency must send a claim to the fiscal intermediary, a private company that contracts with Medicare to pay the bills (in PA, Highmark Medicare Services) Provider of service such as a hospital or home health agency must send a claim to the fiscal intermediary, a private company that contracts with Medicare to pay the bills (in PA, Highmark Medicare Services) Part B services and supplies Part B services and supplies Provider of covered service or supply must send a claim to the Medicare carrier, a private company that contracts with Medicare to pay Part B claims (in PA, Highmark Medicare Services) Provider of covered service or supply must send a claim to the Medicare carrier, a private company that contracts with Medicare to pay Part B claims (in PA, Highmark Medicare Services) DME MAC in Pennsylvania is National Heritage Insurance DME MAC in Pennsylvania is National Heritage Insurance

58 Protecting the Medicare Trust Fund Medicare Integrity Program (MIP) Medicare Integrity Program (MIP) Medical Review process Medical Review process Review claims Review claims Target problem areas Target problem areas Validate claim errors Validate claim errors Classify severity of problems, collect overpayments, develop corrective action plan Classify severity of problems, collect overpayments, develop corrective action plan

59 Medicare Coverage Determinations Two types of coverage determinations assist providers and suppliers in correctly coding and billing Medicare only for covered items and services Two types of coverage determinations assist providers and suppliers in correctly coding and billing Medicare only for covered items and services National Coverage Determinations (NCDs) National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Local Coverage Determinations (LCDs)

60 Medicare Coverage Determinations, cont’d National Coverage Determinations (NCDs) National Coverage Determinations (NCDs) Specify the extent to which Medicare will cover specific services, procedures, or technologies on a national basis Specify the extent to which Medicare will cover specific services, procedures, or technologies on a national basis Medicare contractors are required to follow NCDs Medicare contractors are required to follow NCDs Local Coverage Determinations (LCD) Local Coverage Determinations (LCD) Made in the absence of a specific NCD by local Medicare Contractors Made in the absence of a specific NCD by local Medicare Contractors Outline coverage criteria, define medical necessity, provide codes that describe what is and is not covered Outline coverage criteria, define medical necessity, provide codes that describe what is and is not covered

61 Protecting the Medicare Trust Fund Fraud and Abuse Fraud and Abuse Potential legal actions Potential legal actions Investigations, civil monetary penalties, suspend payment, exclude from participation Investigations, civil monetary penalties, suspend payment, exclude from participation OIG OIG

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63 References 1. National Health Expenditure Accounts 2006 Highlights. CMS Website. Available at: ccountsHistorical.asp. Accessed January 18, ccountsHistorical.asp. Accessed January 18, ccountsHistorical.asp. Accessed January 18, The Nation’s Health Dollar, Calendar Year CMS Website. Available at: SourcesExpenditures2006.pdf. Accessed January 18, SourcesExpenditures2006.pdf. Accessed January 18 SourcesExpenditures2006.pdf. Accessed January Pompei P, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 6 th ed. New York: American Geriatrics Society; Social Security: A Brief History. Social Security Website. Available at: Accessed January 18, Accessed January 18,2008 Accessed January 18, Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals. CMS; 2006.

64 References, cont’d 1. Brief Summaries of Medicare and Medicaid. CMS Website. Available at: reMedicaidSummaries2007.pdf. Accessed January 18, reMedicaidSummaries2007.pdf. Accessed January 18 reMedicaidSummaries2007.pdf. Accessed January Medicare & You CMS Website. Available at: Accessed January 3, Accessed January 3 Accessed January 3


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