1. Medicare and Medicaid Basics
NSLHA Convention 2018
Presented by Candace Grantham MS. CCC-SLP

2. Objective
Participants will understand the basic differences between Medicare and Medicaid.
Participants will understand basic requirements and funding for Medicare and Medicaid.
Participants will understand differences in Medicare Parts A, B, C and D.
Participants will understand provider identifier numbers and where to apply for a number.
Participants will understand basic information about Medicaid, CHIPS and Medicaid in the public schools (MIPS)

3. About Me
I am a SLP currently working for ESU 5 full time, and per diem in the skilled nursing/rehabilitation setting for Select Rehabilitation.
In my past life I spent time as a medical biller and office manager for a family practice medical facility in Bakersfield, California. I have also served as the rehab manager in the skilled setting.
I carry teaching credentials for K-8 Multiple subjects, 6-8 English Language Arts with an emphasis in ESL, and a reading credential.
I received my BA and MA in Education and Reading from California State University Bakersfield, my MS in Communication Disorders from Nova Southeastern Florida.

4. Medicare Short Course
Was established through amendments to the Social Security Act in 1965.
It was designed as supplemental hospital insurance to people over age 65. Over time it has expanded to include persons with permanent disabilities.
There are enrollment periods from October 15 to December 7 each year. People are also eligible within a window of turning 65.
The hospitalization section is known as PART A Medicare has no out of pocket premiums. In a sense they were collected from our paycheck in prior years.
Part B, C and D Medicare all require a premium payment.

5. Part A Medicare
The hospitalization section is known as PART A Medicare has no out of pocket premiums. In a sense they were collected from our paycheck in prior years.
Although Part A is known as hospitalization, it also extends beyond the hospital to rehabilitation settings as long as the 3 day inpatient stay qualification has been met.
Sometimes a patient will be “admitted” under observation status and found that the condition does not warrant the high level of care provided in the hospital, they are discharged out to a rehabilitation, home health or skilled nursing setting before the 3 day stay. The coverage then rolls to Part B or C Medicare.
As a therapist working in a rehabilitation setting, you may hear talk of RUG levels and ARD.
If a patient is admitted where the payor source is Medicare part A-it is important to know and understand that your minutes count...or not! The or not part makes managers grouchy:))
The reimbursement for therapy (and the stay in general) is divided into categories which translates to # of $$ the faciity sees. The lower the RUG level the lower the payment. If a patient were expected to physically participate in 700 minutes of therapy per week (ARD plays here) and because you only provided 40/50 minutes of scheduled minutes of therapy on the last day of the patients week - we will be paid at a lower rate for services, but will still have to pay the therapists for their time spent, this translates to a financial loss. Your therapy manager will keep close tabs on minutes provided to a Medicare A patient, and so should you.

6. Part B Medicare
Part B Medicare is typically billed as outpatient and fee-for-service.
*This can seem a bit confusing because Part B is utilized in long term settings when a 3 day qualifying stay has not been met.
If you are looking into private practice it is imperative to stay abreast of current coding and fee schedules. ASHA does a good job of keeping an updated resource at
Part B does require a premium and is deducted from your social security check. Part B also requires a 20% co-payment on services.
Medicare B is billed out in units, generally based in minutes-and will differ from setting to setting.

7. Part B Medicare continued
Part B Medicare seems more like what we think of a standard insurance. Under Part B you don’t have to stay within a network of providers.
A patient may opt to also pay for a supplemental insurance plan that will help cover out of pocket expenses (OOP) left from Part B. Depending on the plan you choose it could cover most all OOP or just certain areas.
***Important Audiologists and SLPs can not enter into a private contract with a patient. We have to be enrolled in Medicare to provide any covered service to a beneficiary. That is called opting out-not allowed.

8. More Part B participating vs non
WE can however, be non-participating. Meaning we do not bill Medicare directly. The patient pays for the services and then bills Medicare themselves.
The exception to this is an audiologist that is fitting hearing aids, not diagnosing a condition, they may not be required to enroll as a provider.
These circumstances apply more for people in a private setting.
In other settings hospitals, SNFs, etc. the company is probably going to tell you to get enrolled if you are supposed to be.
Participating means the bills are sent directly to Medicare and you are enrolled.

9. Part C Medicare
Part C Medicare or Medicare Advantage Plans (MA) are contracts between Centers for Medicare Services ( CMS) and a private company to manage the Medicare patient’s services.
Part C must include all benefits that are offered in Part A and B *except hospital services, and may also include services such as prescription, vision, dental, etc.
Part C services will be administered via an Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). In either case outside of a doctor visit (doctor has to be determined prior), generally a patient must have authorization for visits and procedures,
As a provider you must clarify the patient's insurance type. You can not bill an HMO unless you are part of that organization. There are limitations to billing a patient who has a PPO as well. In short you may not be paid for your services unless you are a contracted provider and have appropriate authorizations in place.

10. Medicare Part D - Prescription Coverage
Many companies offer Part D and the cost and coverage varies greatly.
Patients may ask if your services (because a physician writes a “prescription” for therapy) or any durable medical equipment (DME) affects the donut hole, typically it does not. This is when a level of out of pocket expense (OOP) has been met, then the patient pays full price for a specific dollar amount. When that is met part D kicks back in at 100% coverage amount. *Confused* me too!
We won’t spend too much time here as we don’t write RX that are billable under the drug plans. I have had only one instance of confusion of a patient's part, he thought since a physician wrote on a rx pad for him to have chiropractic care-that his drug plan would cover that...

11. Medicaid short course http://dhhs.ne.gov/medicaid/Pages/med_ph.aspx
*no enrollment periods
**is income dependent
***no premiums to participate
Persons may experience out of pocket costs which can vary depending upon income and share cost status

12. Medicaid
Federal and State governments both fund Medicaid. Heritage Health is the MCO managing Nebraska’s Medicaid program. (MCO=managed care organization).
If you move between state you may notice differences because states are allowed in enhance coverages over what the Federal Government has mandated. (funded)
You must meet certain eligibility requirements. Some of these groups are elderly, blind, disabled low income pregnant women, children. In general there is an income verification attached to qualification.
A person can have Medicare and Medicaid at the same time-if they meet qualifications.
Note recent budget proposals indicate a 1% pay cut across the board including providers.

13. CHIP Children’s Health Ins. Program
In Nebraska this program is funded by Medicaid. It pays for covered medical services for persons who are unable to afford such.
There are income guidelines as well and is for persons 18 yrs old and under.
The following Health Ins. Companies administer the CHIP in Nebraska:
Nebraska Total Care, United Health Care, and Well Care health plans.
**As a provider, if you are already enrolled to provide services to Medicaid clients you are automatically able to provide services to CHIP clients-HOWEVER you probably have to enroll with the aforementioned companies as well.
We have represenatives in the audience that may be available for specific questions.

14. CHIPS
Children's Health Insurance program is also jointly funded by the State and Federal Government.
CHIPS provides for many of the typical health related visits- well checks, immunizations, illness, fractures etc.
Just as with Medicaid depending upon the qualifications of the family, there may or may not be out of pocket expenses.
In terms of therapy (ST. PT, Aud. or OT) * experience and what I could find within the MCO, if therapy can be provided within the school system they would not cover add’l therapy.

15. Which brings us to MIPS Medicaid in the Public Schools.
Your public school employer may ask for your UPIN, state license #, or other verifying identifiers, we have to be enrolled with Nebraska Medicaid to bill.
Public schools may receive Medicaid funds for some health services provided to students at school. The services must be medically necessary, the student must be eligible for Medicaid, and special education and services must be included in their Individual Education Plan (IEP) or Individualized Family Service Plan (IFSp)

16. Billing MIPS
Yes, we have to document our visits and time with students that qualify for MIPS.
Your ESU/or school district will tell you the name of students that are Medicaid eligible for each month. You will bill only for the names you are given.
There are 2 pools for billing- Medical and administrative, they are mutually exclusive.
A few times during the school year you will be asked to log into a large billing system to complete a random moment in time survey. The state uses this information to make periodic payments to schools.
Students must be medicaid eligible and have an IEP, IFSP in order to include them in billing.
Students must have a physician referral for therapy, therapy must be overseen by a physician, PA or LNP.
**most schools have you covered not to worry. As a general rule there is a physician that is contracted to the schools for this purpose.
In recently reimbursement changed from a per unit system to a per visit system..however you still have to keep track of in/out or actual time spent. Last I knew there was still discussion at the legislative level so it may change again.

17. MIPS
Monthly you will be asked to also complete a billing form for each eligible student.
This will differ from ESU to ESU.
Using this information each year the Unit completes a settlement. Here the payment from the RMT survey is compared to the actual costs and a balance payment is made to the schools.

18. Billing requirements
Name of Child: Date of Birth: Diagnosis: Date of service: Duration of Service (Time in and Time out): IEP/IFSP Treatment Goal: Progress: Signature and Credentials of the servicing provider:
Requirements for direct service documentation • Records must be kept for at least 6 years. • Documentation must include name, demographic information, diagnosis or need for the service. • Document for each date of service are required. • Evaluations. • Ensure that treatment goals and a Plan of Care must be part of the documentation.

19. Billing requirements
• Recertification that the care is appropriate for the client’s needs and should continue. • Progress notes for each date of service. • Documentation from ordering physician, physician’s assistant, or certified nurse practitioner IEP, IFSP or MDT Plans • The order, prescription, or treatment plan of an ordering professional. The signed IEP/IFSP is acceptable. • The signature, credential, and signature date of the provider • Documentation must be legible • Documentation should be available in the client’s file at the time a claim is submitted for reimbursement.