1 Welcome to Medicare Training!

2  Aged (65 or older)  Permanently Disabled  End Stage Renal Disease What is Medicare? Medicare is a federal health insurance program set up by Congress for the following:

3  Ensuring the identification of patient’s name, date of birth and Health Insurance Claim Number are entered correctly.  Verifying that the patient is in fact eligible for Medicare benefits.  Assigning the correct coverage and completing the required payor information.  Determining if the patient has other insurance coverage and which insurance is the primary.  Identifying any Medicare supplemental insurance coverage the patient may have. Critical registration concerns

4 Part A -Hospital coverage which covers inpatient services. Part B - Medical coverage which covers outpatient hospital services and physician services. What types of Medicare coverage are there?

5  Aged 65 or older:  Must be citizen or permanent resident of the U.S.  Individual or their spouse must have worked 40 quarters (or 10 years) in Medicare covered employment Who is eligible for coverage? If an individual qualifies for Part A, they are then eligible to purchase Part B coverage. The following are the various ways an individual may be eligible for Medicare Part A coverage:

6  Permanent Disability:  Under the age of 65  Must have received Social Security or Railroad Retirement Board Disability for at least 24 months Who is eligible for coverage?  End Stage Renal Disease:  Individual diagnosed with ESRD and receiving kidney dialysis or a kidney transplant

7 There are circumstances where an individual is not eligible for both parts, but may be eligible to purchase one or the other. Some individuals who have not worked the full 40 quarters in Medicare-covered employment may be eligible to purchase Part A when they reach 65 years of age. Likewise, an individual who is not eligible for Part A coverage, but is a U.S. citizen or permanent resident may have the option to purchase only Part B when they turn 65. This is how an individual may only be covered under one Medicare Part and not both. What are the critical concerns?

8 One of the most critical pieces of information is the HIC number. The HIC number includes the social security number of the primary person eligible for the coverage. This could be either the patient, spouse, or parent. It also includes an alpha suffix or prefix connected to the social security number. This letter code identifies how the patient has qualified for their Medicare benefits. Critical pieces of information…. Both the number and the letter suffix (or prefix) are required to properly identify the patient’s coverage and ensure Medicare payment.

9 A (suffix)Primary wage earner who has paid into the Medicare program A (prefix)Retired railroad worker BThe beneficiary is the wife of the primary wage earner B1The beneficiary is the husband of the primary wage earner CThe beneficiary is a child of the primary wage earner Most common suffixes and prefixes are:

10 Subscriber Info Screen Medicare Card EXACT MATCH It is critical that the registrar verify that the name being used in the

11 If the patient’s name is incorrect on the Medicare card, the patient’s correct name should continue to be used in the patient demographic screens of the registration. However, in order to bill Medicare, the name on the Medicare Coverage Wizard needs to be changed to match the name found on the Medicare card. This is accomplished by simply manually typing the information in the appropriate fields on the Subscriber Info screen. There are occasions when the name listed on the Medicare card is spelled incorrectly.

12 Medicare Card Patient’s Name Patient’s HIC Entitled Coverage Effective Dates What information do I need from the Medicare card?

13 The Original or Traditional Medicare offers basic coverage, but does not include many preventive services. What types of plans does Medicare offers for its patients? Result = High out of pocket cost to the patient For this reason, a patient may opt to be covered through another plan based on their healthcare and financial needs. Medicare patients do have a choice in their healthcare benefits.

14  HMO- Health Maintenance Organization  PPO- Preferred Provider Organization  FFS- Fee for Service Medicare Advantage The Medicare Advantage plans are administered by insurance companies and are available throughout the country based on the patient’s residence. Medicare provides coverage through Medicare Advantage plans (formerly called Medicare + Choice). These plans include:

15 Be eligible for premium-free Part A coverage Pay the Part B premium Pay the Medicare Advantage monthly premium To Enroll in a Medicare Advantage plan, the patient must: Once a patient purchases a Medicare Advantage plan, they are no longer covered under the original Medicare plan. Registration is to use the appropriate health plan payor and not the original Medicare payor.

16 Blue Cross-Senior Secure Blue Shield-65 Plus Healthnet-Seniority Plus Kaiser-Senior Advantage AARP Medicare Complete- HMO Care 1 st Humana Easy Choice Aetna Medicare Select Plans Available in San Diego and surrounding areas are:

17 Medi-Gap (Supplemental) Instead of the Medicare Advantage plan, a patient may have opted to purchase a Medi-Gap policy, titled as such because it fills in the gaps to Medicare. This policy is referred to as supplemental coverage because it typically covers the deductibles and co-insurance amounts for which the patient is responsible and is always secondary to the Medicare coverage. There are 10 different Medi-Gap plans which are titled A-J depending on what the plan covers. Just like the Medicare Advantage plans the Medi-Gap policies also have a monthly premium in addition to the Part B premium which the patient is responsible for. These supplemental plans are only purchased along with the Original Medicare plan and not the Medicare Advantage plan.

18 Part A (Hospital Insurance) Inpatient hospital, inpatient skilled nursing facility, home health, hospice, inpatient comprehensive rehab facility, and End Stage Renal Disease Part B (Medical Insurance) Physician services, non-physician services, diagnostic tests, outpatient hospital services, durable medical equipment, and ambulance transportation What coverage is provided at UCSD Healthcare?

19 No. Only the prenatal and delivery of the Medicare insured will be covered. Alternate funding will need to be secured for the newborn child of a mother with Medicare coverage Is there any coverage for newborns?

20 In addition to the Original Medicare plan, Medicare Advantage and Medi-Gap, patients may be covered by an Employer Health Group Plan Worker’s Compensation Third Party Liability Carrier What other coverage might a patient have?

21 As required by Federal Government and CMS (Centers for Medicare and Medicaid Services) there is a formal questionnaire that needs to be completed to determine if the patient has insurance coverage that should be considered primary to Medicare. MSP Questionnaire

22 Medicare Secondary Payor Questionnaire What is MSP Questionnaire? The areas where the MSP looks for primary responsibility are when the illness/injury is covered by: An employer group health plan (EGHP) or large group health plan (LGHP) Worker’s Compensation Non-work-related accidents such as auto accidents, accidents in the home or any other illness or injury where another party is responsible

23 $6 billion/annually Since enacted, Medicare saved in excess of

24 Failure to comply will result in penalties: Payment denial to the services rendered Civil penalty up to $2,000 for each occurrence MSP Questionnaire is Mandatory MSP Questionnaire must be completed and documented for each episode of care: Inpatient stay Each emergency department visit Every outpatient encounter When and how is the MSP used to determine financial responsibility?

25 Medicare Secondary Payor Scenarios Patient is covered by Employer Group Health Plan through their own or their spouse’s current employment Does the employer employ 20 or more employees? EGHP primary Medicare Secondary Medicare primary EGHP Secondary YesNo Aged and Currently Working

26 AARP- claims are administered by United Healthcare. Anthem Blue Cross Medi-Gap Supplemental Policies There are variety of organizations and insurance companies that provide supplemental coverage, such as: All other supplemental plans should be coded by viewing the insurance card and using the Insurance Master List to select the correct coverage.

27 Eligibility for Medicare patients is verified via the Common Working File (CWF) which is managed by the Medicare program. For UCSD registration staff, the CWF is accessed via the RTE system. It is very important to verify Medicare eligibility prior to services. If the patient is not eligible for Medicare benefits, then an alternate funding source must be identified. It is also critical that any Medicare HMO coverage be identified at the time of registration. How do I determine if patient is eligible for services?

28 The patient’s HIC number including the alpha character The patient’s name as entered in Medicare Common Working File The date of birth What coverage and effective dates Whether a pt is assigned to Medicare HMO or Hospice Part A and B effective dates What information is available? Here is the list of some of the commonly needed information you will find in RTE:

29 Required information to run RTE

30 RTE response for Traditional Medicare

31 RTE response for Medicare Advantage plan

32 Keys to ensure the account will be paid: Proper documentation Verifying eligibility Acquiring authorizations What can I do as a registration person to prepare the account for billing?