Medicare 1

Preferred provider organization plans PPO

Prescription drug coverage usually is included Beneficiary doesn't have to choose a primary care physician Referral is not required to see a specialist in those cases Out of network care is covered, but usually at an additional cost

HMO health maintenance organization plans

Prescription drug coverage usually is included Beneficiary must choose a primary care physician referral is required to see a specialist in most cases No coverage for out of network care, except for POS plans where it is covered at an additional cost

Part A

Primarily to Provides hospital insurance and pays for certain other types of institutional care

Part B

Primarily to provide medical insurance for physicians visits and other outpatient care

Special enrollment period SEP

Provides an exception to the late enrollment penalty for individuals who delete enrollment in part B because they or their selves are still working and they already have coverage through employer-sponsored group health insurance. Individuals can sign up for Medicare coverage without a late enrollment penalty all during the time they or their spouse remains employed and the employer sponsored group health coverage is in effect. The special enrollment period continues for eight months following the month that they lose their group health insurance, either by retiring or otherwise. Part B coverage starts the month after the election is made. The special enrollment period is only made available to active workers covered by employer sponsored group health insurance. COBRE coverage or retiree group health insurance (coverage provided to former workers who have retired)does not qualify

Part D

Provides coverage for prescription drugs

Part C

Provides expanded coverage through managed care plans such as health maintenance organization HMOs and preferred provider organization's PPOs

Conditions for eligibility for home health care

A physician or other healthcare professional working with a physician must see the beneficiary in person and certify that home health services are needed. The care must be provided under a physicians order by a Medicare certified home health agency.

Payment of Claims...Medicare administrative contractor MAC

A private firm contracted by Medicare to handle its claims processing. A single contractor handles all the claims for a region that includes several states. Medicare claims are generally submitted to Medicare by the healthcare provider. The Medicare administrative contractor checks the claims to make sure that services are coded correctly and make payments to the provider. Medicare administrative contractors also enroll healthcare providers in the Medicare program and train providers in its procedures

URC Veredict

If the URC determines that a Medicare beneficiary does not need to be admitted or, if admitted, does not need to stay in the facility, it must notify the patient, the practitioner, and the hospital within two days after the determination. If the URC reviews an "outlier case", it must do so no later than seven days after the DRG limits have been reached

Eligibility for hospice care

In addition to being certified by a physician as having a terminal illness which is having a life expectancy of six months or less, the Medicare beneficiary must agree to forgo any treatment that would attempt to cure the terminal illness. Medicare will still pay for covered services for health problems not related to the terminal illness. The hospice care provider must be Medicare approved.

Part D

Part D, like part B, is funded partially by general tax revenues and partially by premiums paid by part D beneficiaries. However, part D premiums are paid to the provider of a part D plan rather than the federal government as part B premiums are.

SNF requirements

To qualify for the benefit, a Medicare beneficiary must be admitted to the skilled nursing facility: Within a short time generally no longer than 30 days, after being discharged from the hospital in which the beneficiary Was an inpatient for at least three consecutive days

Requirements for home health care

To receive home health services under Medicare, the beneficiary must be homebound, meaning that both of the following apply: The beneficiary is normally unable to leave home, and doing so requires considerable time and effort and Because of an illness or injury, leaving home is not medically advisable or is not possible without the aid of support devices, special transportation, or assistance from another person

URC purpose

To review all aspects of care being submitted to Medicare for payments, such as admissions, treatment, and length of stay. Facilities being paid under the prospective payment system need to review only those cases that are assumed to be outside a diagnosis related groups parameters. Such cases are called outliers. Facilities not paid under the PPS make a periodic review of all inpatient cases

Original Medicare

Together, parts A and B are referred to as original Medicare because those two parts were enacted together in the original amendment to Social Security that created the Medicare program in 1965

Inpatient hospital care....Benefits periods

Under Medicare part A, a benefit period is defied as a period of time that: Begins on the first day that a beneficiary is admitted to the hospital as an inpatient and Ends on the 60th day after the beneficiary has been discharged If a beneficiary is readmitted to the hospital within 60 days of being discharged, the readmission is considered to be an extension of the initial benefit period Rather than the start of a new period. The definition of a benefits. Is important in determining the benefits to which Medicare beneficiaries are entitled and the portion of the cost they are responsible for paying

Elgibility for Medicare part D

Under the provision of part D voluntary prescription drug coverage, anyone entitled to or enrolled in part a and or part B of Medicare meeting a role in the volunteer prescription drug program in his or her area.

Respite care under hospice care

Usually, hospice care is provided in the Medicare beneficiaries home were a spouse, and adult child, or a friend provides for the beneficiaries personal care needs. Recognizing that providing personal care to be terminally ill person can be exhausting, Medicare to hospice coverage includes a respite care benefit. If the at home caregiver needs a rest, the hospice care provider can arrange for the patient to be moved to an inpatient facility where the institutional care will be provided for a period of up to five days. After the respite., The Medicare beneficiary is returned to the home setting

When can beneficiaries join, switch or dropping Medicare part D plan

When They first become eligible for Medicare and Between October 15 and December 7, with coverage beginning the following January 1 Joining a Medicare part D plan is on the customers initiative. Medicare part D plans are not allowed to call anyone to enroll in a plan.

Utilization and review committee URC

All entities providing services paid for by Medicare or Medicaid are to have a utilization and review committee URC. This committee is to be comprised of at least two doctors of medicine or osteopath he. No committee member may have a financial interest in the medical facility or have been involved in the care of a case being reviewed.

Other covered services and supplies for Medicare part B

Ambulatory surgical centers-care in an ambulatory surgical center (a facility where surgical procedures are performed and the patient is expected to be released within 24 hours) are covered if they are Medicare approved Home healthcare-same coverage and requirements as described previously for part eight; deductible and coinsurance generally do not apply Outpatient physical therapy, occupational therapy, and speech pathology-The services are covered on an outpatient basis under part B Rural health clinic care-rural health clinic RHC that's furnished many outpatient primary care and preventative health services are located in non-urban areas that are medically undeserved Portable diagnostic x-rays-this technology is used to perform x-rays on individuals that cannot move Other diagnostic tests-medicare covers test used to diagnose illness and injuries Radiation therapy-used in the treatment of cancer Kidney dialysis and transplants-for beneficiaries with end stage renal disease ESRD, Medicare covers three dialysis treatments per week Heart transplants-under certain conditions and in Medicare approved facilities Ambulance transportation-any medical emergency: only covered in non-emergency situations with a written order from a doctor stating that it is medically necessary Blood-same as described previously for part A Preventative services-medicare part B covers a number of preventative services, many of which are not subject to part B deductible or core insurance requirements if the provider excepts assignment; the list follows, indicating where charges apply: Abdominal aortic aneurysm screening Alcohol misuse screening in counseling Bone mass measurements (bone density) Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular disease screenings Cervical and vagina cancer screening Call rectal cancer screenings; no cost for a multi target stool DNA test, fecal occult blood test, flexible sigmoidoscopy, or colonoscopy; coinsurance and any hospital copayments apply for barium enema's or polyp removal during a colonoscopy Depression screening Diabetes screening Diabetes self-management training; deductible and coinsurance supply Flu shots Glaucoma test; deductible, coinsurance, and any hospital payments apply Hepatitis B shots Hepatitis C screening test HIV screening Lung cancer screening Medical nutrition therapy services Obesity screening and counseling Pneumococcal shot Prostate cancer screening; deductible, coinsurance, and any hospital copayments apply Sexually transmitted infections screening in counseling Smoking and tobacco use cessation counseling " welcome to Medicare"Preventative visit ( one time upon part B enrollment) Yearly wellness visit (annual)

First dollar coverage for home health care

Apart from the 20% coinsurance requirements for durable medical equipment, there is no other cost sharing for the Medicare beneficiary on covered home health services no deductibles, copayments, or coinsurance requirements, and no benefit periods.

QIO

Are private, generally not for profit organizations, stopped mostly by doctors and other healthcare professionals. They are trained to review cases, handle complaints, and recommend improvements in the quality of care available throughout the spectrum of care. Q I owe contracts are three years in length.

Medicare beneficiaries who use non-participating providers

Are responsible for charges in excess of the Medicare approved amount File their own claims with Medicare and or Pay the entire the amount of the providers bill at the time of service and wait to be reimbursed by Medicare for any Medicare covered charges

Exclusions for home health Health care

As mentioned previously, Medicare does not cover personal care, such as assistance in performing activities of daily living eating, bathing, dressing, getting in and out of bed, etc.

Medicare summary notice part B

As with part A, beneficiaries are kept apprised of claims activity with the Medicare summary notice. Following is an example listing of the information included in the Medicare summary notice MSN for part B services: Date-The date MSN was sent Customer service information-Who to contact with questions about MSN etc

Exclusions for SNF

As with the inpatient hospital care benefit, a skilled nursing facility benefit does not cover a private room, unless deemed medically necessary, or non-medical services such as television in the room.

Exclusions for hospice care

Because hospice care is generally provided in the Medicare beneficiaries home, the hospice care benefit does not include room and board, except for respite care. Also, once the beneficiary elects hospice care, Medicare will not pay for any treatment or drugs provided in an attempt to cure the terminal illness. To be covered, all services must be provided by or arranged through the Medicare approved hospice care provider chosen by the beneficiary

Deductible for Medicare part B

Before Medicare begins paying for Part B services, Medicare beneficiaries must satisfy the part B deductible. The part B deductible applies on an annual basis, from January through December, as with most other types of Medicare insurance. The amount of the part B annual deductible maybe adjusted each year.

To enroll in a Medicare advantage plan

Beneficiaries must reside in the plans service area. Beneficiaries may not belong to more than one Medicare advantage plan at a time.

QIO mission and function

By law, the mission of the QIO program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. The core functions of the QIO program are; Improving quality of care for beneficiaries Protecting the integrity of the Medicare trust fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting Protecting beneficiaries by expeditiously addressing individual complaints such as: Beneficiary complaints Provider-based notice appeals Violations of the emergency medical treatment and labor act EMTALA CMS relies on QIO to improve the quality of healthcare for all Medicare beneficiaries. The use of the QIO is legally required by the Social Security act

Medicare savings programs (MSPs)

Certain low income individuals may qualify for state run Medicare savings programs that provide help with paying some of the cost for Medicare coverage. In addition to income requirements, the total value of beneficiaries assets was also fabulous certain threshold that may be adjusted for inflation each year. A minimum asset limit is established by the federal government, but states may said hire that is, more generous, threshold.

Medicare conditional payment (subrogation)

Certain types of Insurance are generally primary to Medicare; that is, they will pay first even if Medicare covers his services a beneficiary receives. Types of insurance that are primary to Medicare include: Workers compensation No fault insurance, including automobile insurance Liability insurance, including self insurance Black lung benefits Black lung benefits Claims filed under these types of coverages are not always settled quickly. Even if the claimant eventually wins a settlement, the outcome may be uncertain and claimants may have to pay for healthcare services out of their own pocket in the meantime. In such cases, Medicare may pay for covered services on a conditional basis. If Medicare beneficiary later receive the settlements covering healthcare costs for which Medicare made a conditional payments, the beneficiary will be required to pay the amount of the conditional payments back to Medicare.

Information included in a Medicare summary notice for Part A includes

Date-The date the notice was sent Customer service information-Who to contact with questions about the MSN Medicare number Name and address Be informed section-Messages about ways to protect from fraud and abuse Part A hospital insurance-inpatient claims-Type of service: see the back of the MSN for additional information. Please note: for outpatient services, this section is called part B medical insurance-outpatient facility claims Date of services -date service was provided Claim number - number that identifies the specific claim Benefits days used - shows the number of days used in the benefit period (for outpatient services, this column is called "amount charged") Non-covered charges-Show the charges for services denied or excluded by the Medicare program Deductible and coinsurance-The amount applied to the deductible and coinsurance You may be billed-The total amount of the provider may bill, including deductibles, coinsurance, and noncovered charges: Medicare supplement ( Medigap) policies may pay all or part of this amount See notes section-if a letter appears, refer to the notes section for an explanation Providers name and address-facilities name and billing address, and referring doctors name Notes section-provide additional explanation and more detailed information about certain items in the claim Deductible information-how much of a deductible has been met for the benefit period General information-Important Medicare news and information Appeals information-how and when to request an appeal

Diagnosis related groups DRGs

Each Medicare patient is classified into a diagnosis related group on the basis of clinical information. Except for certain patients with exceptionally high cost, called outliers, the hospital is paid a flat rate for the DRG, regardless of the actual service provided. Ex. Suppose Medicare establishes a rate of $2000 to treat a certain condition. If a Medicare beneficiary is admitted to the hospital with that condition, Medicare pays the hospital $2000 regardless of how much it actually cost the hospital to treat the patient. This discourages over treatment of patients, and encourages hospitals to do all they can to deliver care more efficiently.

Minimum standards for Medicare part D

Each year Medicare develops a standard part D plan that expresses the minimum standards that approved part D plans must meet for this calendar year. The elements of the standard plan (and as a point of reference, the amounts for 2016) are: An annual deductible ($360 in 2016) The initial coverage limit ($3310 in 2016), up to which beneficiaries pay 25% of their prescription cost after meeting their deductible; once the prescription drug costs reach the initial coverage limit, beneficiaries pay the full amount of your prescription drug costs, but they receive discounts from their retail prices of those drugs (55% on brand-name drugs and 48% on generic drugs in 2016) The out-of-pocket threshold ($4850 in 2016), above which part D's catastrophic coverage begins; when I total spent on prescription drugs by a beneficiary reaches the out-of-pocket threshold, Medicare begins paying for all of the beneficiaries prescription drugs except for small copayments or coinsurance amount (the greater of 5% or $7.40 on branding drugs and the greater of 5% or $2.95 on generic drugs in 2016)

Open enrollment. 0EP

Each year between October 15 and December 7, Medicare beneficiaries are given an opportunity to make certain changes to their coverage. This is known as the open enrollment. 0EP. During this time, Medicare beneficiaries can: Change from original Medicare to a Medicare advantage plan, or change from a Medicare advantage plan back to original Medicare Switch from one Medicare advantage plan to another Obtain, change, or drop their Medicare part D prescription drug plan coverage

Enrollment in part A and part B

Enrollment in Medicare part A and part B is automatic for people who are already receiving Social Security benefits when they become eligible for Medicare. So, enrollment will be automatically for individuals: at age 65 if they have receive Social Security retirement benefits at that time or after receiving Social Security disability benefits for two years, immediately for those with a LS, even if they are not 65 at a time.

Ex.

For example, suppose Dallas goes to the hospital emergency room after injuring himself in the fall. He is admitted for observation, but after one day it is it German he does not need hospital care. He is then transferred to a skilled nursing facility to receive a physical therapy. Dallas would not qualify for the skilled nursing facility care benefit because prior to his admission to the facility spent only one day in the hospital as an inpatient, rather than the required three days.

Working beneficiaries also covered by employer group health plans

For individuals on Medicare who are still working at age 65 and are also covered by an employer sponsored group health plan, the question arises: which plan is the primary payer in the event of a claim, Medicare or the employers group health plan? The answer depends on the number of people working for the employer. If the employer has: Less than 20 employees, Medicare pays first 20 or more employees, the employers group health plan pays first If the employer's plan is primary but does not pay the entire amount of a claim, Medicare may pay secondary benefits for Medicare covered services. Employers with 20 or more employees must offer employees who are age 65 or over and employees spouses who are 65 or over the same health benefits, under the same conditions, as are offered to younger employees and their spouses. Employees under age 65 who are on Medicare because of a disability must also be offered the same health benefits as all other employees. In the case of employees under age 65 who are on Medicare because of a disability, Medicare is the primary payer if the employer has less than 100 employees. The group health plan is the primary payer for disabled Medicare beneficiaries under age 65 only if the employer Has 100 or more employees.

Additional Part A services...Psychiatric care

For inpatient psychiatric care, Medicare part A will pay for the same kinds of services as if the beneficiary was an inpatient in a general care hospital. Deductibles and coinsurance costs are the same as for a regular inpatient hospital stay. An important distinction from Care and a general hospital is at the inpatient psychiatric facility must be a participating provider - that is, it must except Medicare assignment on all claims. Over a beneficiary lifetime, Medicare will pay for only 190 days of inpatient psychiatric care.

Benefits periods for SNF

For purposes of skilled nursing facility care, a benefit period is defined in the same terms as for inpatient hospital care. But the benefit itself is different

The first 20 days of SNF

For the first 20 days of skilled nursing facility care, Medicare pays the entire cost of covered services

Provider claim filing and Medicare benefits summary notice (Part A)

Generally, part A claims are filed by, and payments are made directly to, the healthcare provider for any coverage services received by a Medicare beneficiary period. To keep Medicare beneficiaries apprised of claim activity, they are sent a Medicare summary notice MSN- and easy-to-read statement that lists health insurance claim information. The MSN provides details of the services received and the amount that may be billed. The notices are sent by the Medicare administrative contractor on a quarterly basis unless the beneficiary is due to receive a payment check from Medicare. In that case, the MSN is mailed to the beneficiary when the claim is processed.

Four main plans of medical advantage plans

Health maintenance organization HMO plans- most HMO have a network of providers that beneficiaries must use exclusively, except for an emergency. Some HMO's offer point of service POS plans that allow beneficiaries to obtain to get some out of network services, but they must be a higher copayment or coin Sherance then for in network care. Preferred provider organization PPO plans- PPOs allow beneficiaries to obtain services from any provider, but they will pay lower coinsurance or co-pay minutes if they use providers in the PPOs network Private Fee-for-service PFFS plans. - TFFS plans allow beneficiaries to go to any provider as long as they except the plans payment term. The plan determines how much it will pay providers and how much beneficiaries must pay for care. Special needs plans SNP's- SNP's provide specialized care for specific group of people such as beneficiary who: Are eligible for both Medicare and Medicaid Live in a nursing home or Suffer from certain chronic medical condition such as end-stage renal disease The most common types of plans are HMOs and PPOs

Hospice care definition

Hospice care is palliative care given to individuals who have a terminal illness. It does not include any treatment that might attempt to cure the disease, only care intended to ease the patient's physical pain and emotional distress.

Coinsurance for Medicare part B

Medicare beneficiaries are generally also responsible for paying coinsurance of 20% on part to be covered services. Medicare pays the other 80% of the Medicare approved charge

Assignment

In the context of Medicare, assignment means that a healthcare provider has agreed to except a predetermined fee established by Medicare as for payment for the services delivered under the program. Is predetermined fee is called the Medicare-approved amount. Healthcare providers that have a greed to except assignment are known as participating providers. While excepting assignment is voluntary, most health care providers have a greed to participate. But individuals should always make sure that their physicians and other healthcare providers do except assignment. To check, individuals can simply ask providers if they except assignment, or they can go to www.medicare.gov/physician or call 1-800 Medicare Even if a provider excepts assignment, the Medicare beneficiary will still be responsible for paying any Medicare deductible and coinsurance amount that apply. However, participating providers will usually wait until they receive their payments from Medicare before they sent a bill to the Medicare beneficiary. Participating providers submit their claims directly to Medicare, so there is also a convenience benefit to using providers that except assignment.

Suffering from ESRD end-stage renal disease that is kidney failure

Individuals under age of 65 can also become eligible for Medicare if they have had a kidney transplant ordered regular dialysis because their kidneys no longer work.

Social Security disability beneficiaries generally after two years

Individuals who have been receiving Social Security benefits because they are disabled and cannot work can become eligible for Medicare or even if they have not trained age 65. Usually, such individuals become eligible for Medicare only after they have received Social Security disability benefits for a period of 24 continuous months. However, individuals who qualify for Social Security disability benefits because they have ALS (amyotrophic lateral sclerosis, also called Lou Gerhrig's disease) are eligible for Medicare immediately

Initial enrollment. IEP

Is a seven month period. That includes the month in which the individual's birthday occurs and the three months on either side. Ex. If Lana turns age 65 in April 2016, her initial enrollment period begins January 1, 2016 and ends on July 31, 2016 Coverage for individuals who sign up for Medicare during the first three months of their initial enrollment period becomes effective on the first day of their birth month. Ex. If Dwayne's birthday is May 18, and he signs up for Medicare in February, March, or April, his coverage becomes effective on May 1. However, there is one exception: if an individual's birthday is on the first day of the month, and the individual signs up during the first three months of the initial enrollment period, coverage becomes effective on the first day of the month prior to his or her birthdate month. Ex. , if Tamra's birthday is on May 1, and she signs up for Medicare in February, March, or April, her coverage becomes effective April 1 Coverage starts later for individuals who sign up for Medicare during your birthday month or in the last three months of their initial enrollment period. For individuals who sign up during their birthday month, coverage starts one month later. For individuals who sign up the month after their birthday month, coverage starts two months later. And for individuals to sign up two or three months after their birthday month (that is, during the last two months of their initial enrollment period), coverage start three months later. The initial enrollment period occurs only ones in an individual's lifetime it does not record

late enrollment penalty

Is designed to guard the program against adverse selection- A disproportionately high number of above average risks in the insurance pool. Adverse election occurs when people who represent an average risk are permitted to delete a purchase of insurance until their health deteriorates and they move into a higher risk category. By encouraging everyone to purchase part B coverage when they are first eligible, elite and Roman penalty maintains the expected balance of average and above average risk in the insurance pool.

Skilled nursing facility (SNF) Care

Is skilled nursing facility SNF is one in which round the clock medical and rehabilitative care is provided by licensed nurses and other medically trained professionals based on the written orders of a physician. It does not include: Intermittent or part-time medical care or Personal, non-medical care such as long-term care or custodial care To qualify for care in a skilled nursing facility, a physician must certify that the Medicare beneficiary requires, on a daily basis, skilled care like intravenous injections or physical therapy that can only be provided by medically trained professionals

Medicare Part A (aka Hospital Insurance or HI)

It's called hospital insurance because the main coverage it provides is for Inpatient hospital care. But it also provides three other types of coverage: Skilled nursing facility care Home health care Hospice care

Part A

Largely funded by the hospital insurance portion of the FICA (federal insurance contributions act) payroll tax collected from workers and employers. Also funded by the premiums paid by individuals who are not automatically covered by Medicare but wish to purchase it when they become eligible. Workers who have paid the hospital insurance tax for at least 10 years and those workers spouses are automatically covered by Medicare part A when they become eligible and do not have to pay the part a premium. Taxes paid on Social Security benefits also help pay for part A benefits

Late penalty amount

Late enrollment penalty is an additional charge of 10% of the amount of the individuals part B premium for every 12 month. That has elapsed since the individual became eligible for Medicare. For example suppose Jack became eligible for Medicare in January 2013 but did not sign up for part B until July 2015. Although Jack waited 18 months after he First became eligible to sign up for part B, only one. Of 12 one months has elapsed, so his penalty will be an additional charge of 10% of his annual premium. The standard premium for part B in 2015 was $104.90. Assuming that Jack, like most people, paid the standard premium, he would be charged an additional $10.49(10% of the standard premium amount) For a total premium of $115.39($104.90 plus the $10.49 penalty). Jack would pay that additional 10% penalty for as long as he had Medicare part B, not just for the first year. If the amount of the standard premium increases, the amount of the penalty would also increase to equal 10% of the higher premium. A similar 10% late enrollment penalty applies to part A coverage for individuals who do not get their part A coverage premium-fee.

Enrollment penalty for part D

Like part B, part D also has a late enrollment penalty. But it is computed differently than the part B late enrollment penalty. The part D late enrollment penalty is an additional amount equal to: 1% of that year's national base part D premium Multiplied by the number of four months that the beneficiary delayed enrollment after first becoming eligible Rounded to the nearest $ .10 So a. Beneficiary or delayed enrollment by nine months would pay a penalty equal to 9% of the national base part B premium, rounded to the nearest $.10. The penalty is payable for as long as a beneficiary has part D coverage, and. It is recalculated each year based on that year's national base part B premium

Exceptions to enroll in Medicare advantage plan

Medicare advantage plans cannot discriminate based on beneficiaries health status. Eligible beneficiaries must be permitted to enroll in a Medicare advantage plan even if they have a pre-existing condition, the only exception is end stage renal disease ESRD. Individuals with end-stage renal disease may be able to join Medicare Advantage that specializes in that condition, if one is available in the individuals service area. Individuals who have had a successful kidney transplant and no longer suffer from the condition may be able to join a Medicare advantage plan. Individuals who are already enrolled in Medicare advantage plan when they develop end stage renal disease must be permitted to standard plan or join another one offered by the same company.

Medicare advantage prescription plans

Medicare advantage prescription plans are for beneficiaries who want to have a Medicare advantage plan. Medicare advantage prescription plans are not available to beneficiaries we have original Medicare. However, not all Medicare advantage plans include prescription drug coverage. Beneficiaries who want a Medicare advantage plan and need prescription drug coverage must make sure they choose a Medicare advantage plan that includes prescription drug benefits. Beneficiaries who have Medicare advantage are generally not allowed to purchase standalone plans even if your Medicare advantage plan does not include prescription drug benefits. There's one exception: beneficiaries enrolled in Medicare advantage private-fee-for-service plans are permitted to purchase a standalone plan if their PFFS plan does not have a prescription drug coverage. But most beneficiaries who have Medicare advantage plan are either in HMO or PPO plans, and the exception does not apply to them. Most Medicare advantage HMO or PPO plans include prescription drug coverage, some do not, so these beneficiaries must choose their Medicare advantage plan carefully if they want prescription drug coverage

Benefit periods for hospice care

Medicare beneficiaries can get hospice care for two 90-day periods followed by an unlimited number of 60-day period's. At the beginning of each benefit period, A hospice doctor or medical director must certify or re-certify that the beneficiary is terminally ill, defined as having a life expectancy of six months or less. The Medicare beneficiary is permitted to change hospice care providers once during each benefit period.

Approved charges/Charge limits

Medicare beneficiaries can obtain services from providers that do not except assignments, but there are some drawbacks. Non-participating providers can charge more than the Medicare approved amount, and Medicare beneficiaries are responsible for paying the difference, in addition to their deductibles and coinsurance. For certain services Medicare beneficiaries who obtain services from a non-participating providers are protected by a rule that prohibits non-participating providers from charging in excess of 15% of the Medicare approved charge. This is known as a limiting charge. Ex. If the Medicare approved amount for a given service was $500, a provider would be limited to charging a Medicare beneficiary no more than $575 for that service even if the provider did not except assignment. However, the limiting charge does not apply to all Medicare coverage services, supplies, and durable medical equipment. If Medicare beneficiaries receive a bill from the nonparticipating provider that seems to exceed the 15% limiting charge, they may have to check with Medicare to see if the charge is correct.

Medicare part C (Medicare advantage)

Medicare beneficiaries who are eligible for both part A and B have the option to choose a Medicare advantage plan. Medicare advantage plans, private healthcare firms approved by Medicare provide beneficiaries with all the benefits included under part A (Except for hospice care) and part B, plus some other benefits like that vary among plans. (To receive hospice care, beneficiaries must elect to receive their benefits through original Medicare.) Beneficiaries that choose a Medicare advantage plan must continue to pay their part B premium and part A premium if they do not receive that coverage premium fee. They may also have to pay an additional premium to the Medicare advantage plan Medicare advantage beneficiaries may also be required to obtain their healthcare services through a network of providers contracted by the Medicare advantage plans they have chosen. But because plans are better able to control costs by maintaining their own provider network, some Medicare advantage plans are able to offer extra benefits without charging an additional premium.

For the next 60 days of each benefit period (Days 91 through 150)

Medicare coverage is provided in the form of lifetime reserve days. For each lifetime reserve day, Medicare still pays most of the cost, but the beneficiary is responsible for coinsurance amount (copayment) that is somewhat larger than the coinsurance amount that applies to days 61 through 90. Also, each Medicare beneficiary is given 60 lifetime reserve days. They are not renewed, so once Medicare has paid for 60 lifetime reserve days, it no longer pays for anything past the 90th day of a benefit period Lifetime reserve days are in exhaustible benefit

Outpatient medical services and supplies for Medicare part B

Medicare covers many diagnostic and treatment services in hospital outpatient departments and other outpatient setting such as clinics. Medicare also pays for approved procedures like x-rays, lab test, blood test, urinalysis, biopsies, casts, stitches, or outpatient surgeries Services received as a hospital outpatient may cost more than similar care a beneficiary receives in a doctors office. In addition to the amount paid to the doctor, beneficiaries are also usually charge a hospital copayment for each service delivered by hospital outpatient department. They are some limits- in most cases, Medicare rules prohibit the copayment for exceeding the amount of the part a hospital deductible for each service

Covered services for Medicare part B......Dr. care

Medicare covers medically necessary doctor services. It also cover services provided by other healthcare providers, like physician assistance, nurse practitioners, social workers, physical therapist, and psychologist.

Exclusions

Medicare part A will not pay for a private hospital room, unless it is deemed to be medically necessary, or for non-medical charges such as a television in the room. Also Medicare does not cover the following types of care: Long-term care or custodial care (personal, non-medical care that can be provided by persons without medical training) Homemaker services Homemaker services private nursing Cosmetic surgery (unless medically necessary such as facial reconstruction) Experimental or alternative medicines or procedures, such as acupuncture Routine dental care or dentures Eye exams related to prescribing eyeglasses Hearing aids and exams for fitting them

Prescription plan options

Medicare part D plans come in the following forms: Stand alone plans, sometimes referred to as PDP's prescription drug plans, which are not part of any other plans; and Plans that are integrated into Medicare advantage plans, sometimes referred to as MA -PD's (Medicare advantage- prescription drugs) The type of plan beneficiaries may choose depend on how they have chosen to receive their other Medicare benefits

Additional Part A services...Blood deductible

Medicare pays for all blood required by beneficiary to receive covered treatment, except the first 3 pints. The first 3 pints must either be paid for by the patient, or donated on behalf of the beneficiary by family or friends. Most hospital procedures do not require more than 3 pints of blood.

Next 80 days (Days 21 through 100

Medicare pays most of the cost and beneficiary is responsible for a daily coinsurance amount or copayments that is a higher amount than the inpatient hospital copayment

For the next 30 days of each benefit period (Days 61 through 90)

Medicare pays most of the cost and the beneficiary pays a daily copayment. The copayment is referred to as the daily coinsurance amount in Medicare terminology, but it is actually a copayment because it is a flat daily amount rather than a percentage of the cost. This coverage for days 61 through 90 is also an inexhaustible benefit.

For the first 60 days of each benefit period

Medicare pays the entire cost of covered services, minus the amount of the part A deductible. No matter how many benefit periods Medicare beneficiaries have in their lifetime, Medicare always pays the entire cost of the first 60 days, minus the deductible. This is referred to as an inexhaustible benefit.

Other concepts...Prospective payment system PPS

Medicare prospective payment system PPS was introduced by the federal government in October, 1983, as a way to change hospital behavior through financial incentives that encourage more cost efficient delivery of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. The predetermined amount is based on the diagnosis related group DRG into which the patient's condition fall

Deductibles for SNF

No deductible applies to the skilled nursing facility care benefit. However, the beneficiary will be responsible for the deductible on the inpatient hospital stay that must proceed admission to the skilled nursing facility in order for the care to be covered by Medicare. After 100 days, the Medicare beneficiary is responsible for 100% of the cost of the care in the skilled nursing facility.

Covered Expenses

Note that Medicare only pays for covered expenses. These include the following: Semi-private room Meals General nursing Miscellaneous hospital services and supplies, such as: Prescription drugs administered in the hospital. X-rays Laboratory test Operating and recovery room charges Rehabilitative services

Open Romans. For Medicare advantage

October 15 through December 7 is open enrollment for the beneficiaries which have an option to choose a different Medicare advantage plan or switch to original Medicare. Between January 1 and February 14 Medicare advantage beneficiaries are also permitted to switch to original Medicare but they cannot change to another Medicare advantage plan during that period

Part C

Often referred to as Medicare advantage, is a combination of part A and part B (original Medicare) coverage plus additional benefits not covered by original Medicare such as hearing or vision care. These additional benefits vary depending on the particular Medicare advantage plan in which the individual is enrolled. The part A and part B benefits provided under Medicare Advantage plans are funded by the same source as a part A and part B benefits provided under Original Medicare. Additional benefits are funded by the additional premium that Medicare Advantage beneficiaries pay to their plan provider

If covered by Social Security..

Part A is premium-free. Part B is not. Individuals who are automatically enrolled in part B have the option to drop it if they do not wish to pay the premium. However, people who do not enroll in Medicare part B when they are first eligible generally have to pay a penalty in the form of a higher premium if they wish to sign up for it later.

Exclusions for Medicare part B

Part B does not pay for the following: Cosmetic surgery, unless medically necessary Experimental procedures Hearing aids and fittings Chiropractic services, except for treatment of subluxation which is partial dislocation of the spine Most eyeglasses and eye exams Most dentures and dental care Prescription drugs that are self administered, except for immunosuppressive drugs, certain anticancer drugs, and drugs use with some types of durable medical equipment such as a nebulizer Personal care such as long-term care or custodial care that can be provided by persons without medical training Care of teens outside of the United States and its territories (the 50 states, the district of Columbia, Puerto Rico, the US Virgin Islands, Guam, the Northern Mariana islands, and America Somoa): however, there are some exceptions, such as when: A Mexican or Canadian hospital is closer though and emergency medical situation occurs in the US or A beneficiary requires care while traveling through Canada en route to Alaska

Part B

Part B is funded partially by general tax revenues and partially by premiums paid to the federal government by Medicare part B beneficiaries. Beneficiaries must pay premium for part B coverage. Most part B beneficiaries pay the standard part B premium, which may be adjusted each year for inflation. Part B beneficiaries whose income exceeds certain threshold pay a higher premium for part B coverage, depending on their level of income and tax filing status. Example, the annual income threshold for higher part B premiums is $85,000 for single people and $170,000 for married couples filing jointly these thresholds are fixed through 2019.

Parts C and D of Medicare

Parts C and D were added later in 1997 and 2003, respect of Lee to keep the Medicare program up to date with changes in the healthcare delivery system

Worker's age 65 and over Medicare Enrollment periods

People must enroll themselves in Medicare. They can only sign up for Medicare during a designated enrollment period. There are three types of Medicare enrollment periods. Initial enrollment. IEP General enrollment. GEP Special enrollment period SEP Each Type of enrollment period has its particular time frame and purpose

General enrollment. GEP

People who miss signing up for Medicare during their initial enrollment. Can still enroll in Medicare during the general enrollment. GEP, which extends from January 1 through March 31 each year. However, coverage for individuals who enroll during a general enrollment period does not become effective until July 1 of that year

Covered services for hospice care

Service is covered under Medicare hospice care benefit include: Anything required for pain relief and symptom management, including drugs Nursing care Social services Certain durable medical equipment Home health aide and homemaker services Grief and spiritual counseling

Medicare/Medicaid eligible

Some beneficiaries are dual eligible, that is, they are eligible for both Medicare and Medicaid. In such cases, Medicare helps pay for their prescription drugs instead of Medicaid. Because they have Medicaid, Medicare automatically gives an extra help with paying for their Medicare part D plan and prescription drugs cost. Medicaid beneficiaries who have not yet joined the Medicare part D plan will be automatically enrolled in one by Medicare to make sure they have drug coverage.

Employer sponsored retirement plans

Some retirees have employer sponsored retiree group health insurance, and because these plans are intended for retired people who are presumably eligible for Medicare, they generally require in shorts to sign up for both part a and part B of Medicare in order to get full benefits under their retiree plans. Also, retiree group health plans are usually designed to fill in the gap's in Medicare coverage. For many years, Medicare did not offer prescription drug coverage, so many retiree group health plans do. Individuals with retiree group health plans Do. Individuals with retiree group health coverage need to check and make sure they understand how the retiree health plan works in conjunction with Medicare

Qualified Medicare beneficiary (QMB)

This program is for persons whose monthly income is no more than the federal poverty level FPL plus $2020. Some states disregard more than an additional $20 of monthly income. In addition to helping pay the part B premium, the QMB program May also help pay beneficiaries part a premium if any and Medicare cost sharing amounts such as deductibles, coinsurance, and copayments

stand-alone plans

Stan-alone plans are for beneficiaries who have original Medicare: part A, part B, or both. Original Medicare does not offer prescription drug coverage, beneficiaries who have original Medicare and one prescription drug coverage for Medicare must obtain it through a standalone plan. Also, beneficiaries who have only part a or part B and one prescription drug coverage for Medicare can only obtain it through a stand-alone plan, since beneficiaries cannot join a Medicare advantage plan unless they have both part a and part B

Examples of benefit periods

Suppose Anita, a Medicare beneficiary, was admitted to the hospital September 1. After 45 days, anita is discharged, but five days later she is readmitted with the same condition. Because she was readmitted within 60 days of her discharge, her readmission is considered to be an extension of her initial benefit period Rather than the start of a new benefit. Period Therefore, anita does not have to pay another deductible However, that also means that anita is already 45 days into the benefit priod, so she has only 15 days of a full inpatient hospital coverage left. Suppose she remains in the hospital for another 85 days. Medicare will pay the full cost of the first 15 of those days. For the next 30 days, anita will be responsible for the coinsurance amount that applies to the days 61 through 90 of an inpatient hospital stay. For the last 40 days of her hospital stay, anita will be able to use her lifetime reserve days. At that point, anita is discharged. If she remains out of the hospital for 60 days, and then is readmitted, a new benefit period Will begin. Her 60 days of Full coverage and 30 days of partial coverage will be renewed, but she will have only 20 lifetime reserve days left to use if her stay last longer than 90 days.

Ex:

Supposed a doctor bills Medicare $1000 for a procedure, but under Medicare's payment schedule the approved amount for the procedure is $600. Medicare will pay the doctor 80% of the Medicare approved amount which is $480. The beneficiaries coinsurance amount is $120 which is 20% of $600, not $200 which would be 20% of the doctors usual $1000 fee. Also, beneficiary is not responsible for paying charges in excess of 15% of the Medicare approved amount. So in addition to the coinsurance amount, the beneficiary must pay the doctor only another $90 which would be 15% of the Medicare approved charge, not another $400 which would have been the difference between the Medicare approved amount and the doctors usual fee.

Quality improvement organization QIO

The Centers for Medicare and Medicaid services CMS use private firms called quality improvement organizations QIO to help improve service while controlling costs. CMS contracts with one firm in each state, as well as the district of Columbia, Puerto Rico, and the US Virgin Islands, to serve as that states or jurisdictions quality improvement organization.

Coinsurance for hospice care

The Medicare beneficiary is responsible for paying 5% of the Medicare approved amount for respite care. They are no other charges for hospice care services provided in the Medicare beneficiaries home. However, the Medicare beneficiary may be responsible for equal payment of up to five dollars for each outpatient prescription drug provided for pain relief or symptom management.

Medicare part D (prescription drug insurance)

The Medicare prescription drug, improvement and modernization act of 2003, also known as the Medicare modernization act MMA, establish a voluntary prescription drug program known as Medicare part D, effective January 1, 2006. Additionally, MMA provides a program called "extra help" under which certain low income individuals may receive part D premium, deductible, and copayment subsides

Other group and retirement plans

The fishy's who are covered by a union or employer group plan should consult with the plan administrator before discounting their coverage. If they dropped such a plan, they may not be able to get it back. Further, they may not be able to drop a drug coverage without losing all health coverage.

Minimum standard for Medicare part D

The private firms that offer Medicare part D plans are free to design their plans as they wish as long as those plans meet minimum standards established by Medicare. That is, Medicare will approve part D plans that offer better benefits than the standard plan, but not worse. And although Medicare publishes a national base part D premium each year as a benchmark, part D plans are completely free to establish their own premiums. For these reasons, Medicare part D drug coverage and premium is very significantly between insurance approved by Medicare to offer prescription coverage.

Covered services under SNF

The skilled nursing facility care services covered by Medicare include: Semi private room Meals Nursing care Rehabilitative services Medications administered in the facility Miscellaneous and medical supplies

Eligibility

There are three groups a person must fall into to be eligible to enroll in Medicare Age 65 or older social Security disability beneficiaries generally after two years Suffering from ESRD end stage renal disease, that is kidney failure

Home health care....Definition

This is Care provided at home typically buy a visiting nurse or healthcare aid employee by home health agency. Services may include: Nursing care Physical therapy Speech language pathology services Occupational therapy Medical social services such as counseling to help cope with life changes, community resources coordinator, and assistance with financial aid applications Medical social services such as counseling to help cope with life changes, community resources coordinator, and assistance with financial aid applications Part-time or intermittent home health aide services Medical supplies for Use at home Durable equipment, such as a wheelchair (The beneficiary must be time for some coinsurance and durable medical equipment)

Age 65 or older

This is the largest group of Medicare beneficiaries. Most people become eligible for Medicare by reason of age that is, because they have turned age 65

Specified low income Medicare beneficiaries (SLMB)

This program is for persons who monthly income is no more than 120% of the FPL plus $2020. As with the QMB program, some states disregard more than an additional $20 of monthly income. The SLMB program helps pay for only the part B premium, not other Medicare costs .

Medicare Part B (medical insurance)

While Medicare part A is designed to provide coverage mainly for inpatient care, Medicare part B provides coverage for medical care received in other settings: doctors office, outpatient clinic or laboratory, or hospital emergency room or outpatient department, for example

Assignment payment method

With participating providers (those that except assignment (, Medicare claims are filed by, and payment is made directly to the doctor or provider. A providers usual fee may greatly exceed what Medicare will allow, but the higher amount may still appear on the providers bill. In such cases, Medicare will reduce the fee to what is permitted under its schedule. Providers who accept assignment cannot charge the beneficiary for the difference between the providers usual fee and the Medicare approved amount. In addition, the 20% coinsurance amount required under part B must be calculated on the Medicare approved amount, whether or not the provider accepts Assignment. If a provider does not accept assignment, the provider cannot require Medicare beneficiaries to pay charges that exceed the Medicare approved amount by more than 15%