Medicare Ch 14

Medicare largest single medical benefits program in the U.S. is

fedearl program authorized by Congress and administered by the Centers for Medicare and Medicaid Services

Cms is responsible for the operation of the Medicare program and

for selecting Medicare administrative contractors (MACs) to process Medicare fee-for-service Part A, part B, and durable medicine equipment (DME) claims

Medicare Part A
(Medicare is a two part program)

reimburses institutional for inpatient, hospice, and some health home services

Medicare PArt B
(Medicare is a two part program)

reimburses institutional providers for outpatient services and physcicans for inpatient and office services

Medicare Hospital Insurance (medicare Part A)
(Medicare program includes)

pays for inpatient hospital critical care access; skilled nursing facility stays; hospice care; and some home helth care

Medicare Medical Insurance (Medicare Part B)

pays for doc's services; outpatient hospital care; durable medical equip.; and some medical services that are not covered by Part A

Medicare Prescription Drug Plans (Medicare Part D)
(Medicare program includes)

add prescription drug coverage to the Original Medcare plan, some Medicare cost Plans, some Medicare private Fee-For-Service Plans and Medicare Medical Savings Account Plans

Medicare Part A coverage is available to

individuals age 65 and over

Are already receiving retirement benefits from
(Medicare part A covrage is available to individuals age 65 and over who:)

SS or the Railroad retirement Board (RRB)

Are eligible to recieve
(Medicare part A covrage is available to individuals age 65 and over who:)

SS or Railroad benefits but have not yet filed for them

Had Medicare-covered
(Medicare part A covrage is available to individuals age 65 and over who:)

government employment

The privacy Act of 1974 prohibits releaseof info unless

all the listed required info. is accurately provided

Individuals age 65 and over do pay a monthly premiumn for medicare Part A

if they or a spouse paid Medicare taxes while they were working

Upon applying for Medicare Part A and B a seven-month intial enrollment period (Iep) begins that

provides an oppurtunity for the indivdual to enroll in Medicare Part A and /or B

Those who wait untill they actually turn 65 to apply for Medicare will cause a delay in the start of Part B coverage because

they will have to wait untill the next general enrollment period (GEP) which is held Jan 1 through March 31 of each yr

Part B coverage starts on
(GEnerall enrollment period)

july 1st of that year

Part B Premiumn also increased by 10 percent for each year 12 month period during which

an individual was eligible for Part B coverage but did not participate

Under certain circumstances individuals can delay

PArt B enrollment without having to pay higher premiumns

Indivduals age 65 or older who are working
(under certain circumstances Idividuals can delay Part B enrollment w/o having to py higher premiumns)

or whose spouse is working, and who have health group insurance through the employer or union

Diabled individuals who are working and who have group health insurance or
(under certain circumstances Idividuals can delay Part B enrollment w/o having to py higher premiumns)

who have health insurance coverage from a working faimly member

Medicare PArt A (Medicare Hospital Insurance) helps cover inpatient care in

acute care hospitals, critical access hospitals, and skilled nursing facilities

Benefit period begins with the first day of hospilization and ends when

the patient has been out of the hospital for 60 consecutive days

Benefit period is also known as a

spell of illness also called spell of sickness

Lifetime reserve days (60) days may only be used once during a patient's lifetime and are usually

reserved for use during the patient's final, terminal hospital stay

Persons confined to a psychatric hospital are allowed

190 lifetime reserve days instead of the 60 days alloted for a stay in an acute care hospital

Medicare part B also covers some home health services if the patient is

NOT covered by medicare part A


an autonomunous centerally administerd program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and thier families

Medicare limits hospice care to four benefit periods which include

two periods of 90days each, one 30 dya period, final "lifetime" extension of unlimited duration

Respite care

temporary hospilizations of a terminally ill , dependent hospice patient for the purpose of providing relief for the non paid person who has the major day to day responsibility for care of that patient

A patient who is recieving hospice benefits is not eligible for

Medicare Part B services except for those services that are totally unrelated to the terminal illness

Medicare Part B

helps cover physcians services, outpatient care, and othr services not covered by Medicare Part A, includding physical and occupational therapy and some home health care

Physcian fee Schedule also known as

Physcians billing schedule

Reimbursement under the fee schedule is based on relative value units (RVU's) that

consider resources used in providing service (physician work, pratice expense, and malpractice expense)

Medicare advantage Plans (medicare part C) are

health plan options that are aproved by Medicare but managed by private companies

Medicare Medial savings Account (MSA) is
(Medicare Part C)

used by an enrollee to pay healthcare bills, while Medicare pays the cost of a special healthcare policy that has a high deductible (not to exceed $6,0000)

The money depoited anually by medicare into and MSA is maanaged by a
(Medicare Part C)

Medicare approved insurance company or other qualified company

Medicare Prescription drug Plans (medicare Part D) offer

prescription drug coverage to all medicare benficiaries that amy help lower prescription drug costs and help protect against higher drug costs in the future

Medicare part d is optional and individuals who Join
(Medicare Part D)

Medicare drug plan pay a monthly premiumn

This plan requires subscribers to pay
(Medicare Part D)

a mothly premiumn and an anual deductible

Ina Medicare Cost Plan, if the individual recieves health care from a non-netwrok provider the

original Medicare Plan covers the service

Demonstration .pilot program is a

special project that tests improvements in medicare coverage, paymetn and quality of care

Programs of All-iclusive care for the Elderly (PACE)

combine medical, social, and long-term care services for frail people who live and recieve health care in the community

The goal of PACE is to help people stay independent and live in their community as long as possible while

recieving the high quality care they need

A medigap policy provides reimbursement for

out-of-pocket costs not covered by Medicare in addition top those that are the beneficiary's share of healthcare costs

Medicare Select

type of Medigap insurance that requires enrolleed to use a network of providers (docs and hospitals) in order to recieve full benefits.

Medicare has established participating providers (PAR) agreement in which

provider contracts to accpet assignment on all claims submitted to MEDICARE

PAr agreements with Medicare include
(Agrrements with Medicare include)

Direct Payment of all claims, a 5% higher fee schedule than for nonparticipating providers, Publication of an anual region par directory made available to all Medicare patients

For MEdicare purposes, ELECTIVE SURGERY is defined as a surgery that

can be scheduled in advance, is not an emergency; and if delayed, would not result in death or permant impaiment of hearing

The regional MAC for traditional claims is selected by CMS

through a competitive bidding process