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

2. Copyright © 2008 Delmar Learning. All rights reserved. 2 Introduction Medicare is the largest medical program in the United States

3. Copyright © 2008 Delmar Learning. All rights reserved. 3 Medicare Is a Two-Part Program Medicare Part A: –Reimburses institutional providers for inpatient, hospice, and some home health services

4. Copyright © 2008 Delmar Learning. All rights reserved. 4 Medicare Is a Two-Part Program Medicare Part B: –Reimburses institutional providers for outpatient services and physicians for inpatient and office services

5. Copyright © 2008 Delmar Learning. All rights reserved. 5 Medicare Program Includes Medicare Hospital Insurance: –Inpatient hospital critical care access –Skilled nursing facility –Hospice care –Some home health care

6. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 11 Medicare Part A Under Age 65 Have received Social Security or RRB disability for 24 months Have end-stage renal disease

12. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 13 Medicare Part B –Helps pay for physician services –Outpatient hospital care –Some physical and occupational therapy –Some home care

14. Copyright © 2008 Delmar Learning. All rights reserved. 14 Medicare Part C Is managed by private companies but are health plans that are approved by Medicare

15. Copyright © 2008 Delmar Learning. All rights reserved. 15 Medicare Advantage Plans Require referrals to see specialists Offer lower premiums or copayments and deductibles than the original Medicare Plan

16. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 17 Medicare Advantage Plans Coordinate patient care, using networks and referrals –Can help with overall care management and result in cost savings

18. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 19 Medicare Advantage Plans Preferred Provider Organization (PPO) Private fee-for-service plan (PFFS)

20. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 23 MEDIGAP Pays for services that Medicare does not pay for

24. Copyright © 2008 Delmar Learning. All rights reserved. 24 Other Medicare Health Plans Medicare Cost Plans Demonstration/Pilot Program Programs of all-inclusive care for the elderly (PACE)

25. Copyright © 2008 Delmar Learning. All rights reserved. 25 Medicare Cost Plan Is a type of HMO –Works much in the same way that Medicare Advantage Plan does

26. Copyright © 2008 Delmar Learning. All rights reserved. 26 Demonstration/Pilot Program A special Project that tests improvements in Medicare coverage, payment, and quality of care.

27. Copyright © 2008 Delmar Learning. All rights reserved. 27 PACE Combine medical, social, and long-term care services for frail people who live and receive health care in the community

28. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 29 Participating Providers Medicare has an agreement with participating providers to accept assignments on all Medicare claims

30. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 31 The Agreements Include Publication of an annual, regional PAR directory made available to all Medicare patients Faster processing of assigned claims

32. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 38 Privacy Act Date the claim was paid, denied, or suspended General reason the claim was suspended

39. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 44 Medicare Summary Notice Is a monthly statement that is easy to read that clearly lists health insurance claims information

45. Copyright © 2008 Delmar Learning. All rights reserved. 45 Claims Instructions The law says that all Medicare claims must be filed using optical scanning guidelines.

46. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 47 Medicare-Medicaid Crossover A Medicare-Medicaid crossover plan provides both Medicare and Medicaid coverage to certain eligible beneficiaries

48. Copyright © 2008 Delmar Learning. All rights reserved. 48 Medicare as Secondary Payer Claims Medicare Secondary Payer (MSP) program –Organizes benefits between Medicare and additional payers to determine if an additional insurance plan is primary.

49. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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