Medicare OT 232 Chapter 10 1OT 232 Chapter 10

Medicare Established?! – 1965 Managed by?! – CMS under… – DHHS Eligible beneficiaries – 65+ – Disabled adults – Individuals disabled before 18 – Spouses of entitled individuals – Retired federal employees and their spouses – Individuals with end-stage renal disease OT 232 Chapter 102

Medicare Part A Hospital Insurance – Hospital care – Skilled nursing facility care – Home health care – Hospice care Automatic enrollment No premium if eligible, but may require deductibles or copays Table 10.1, page 338 OT 232 Chapter 103

Medicare Part B Supplementary Medical Insurance Helps with – Physician services – Outpatient hospital – Medical equipment Voluntary program, coverage is NOT automatic Premium involved, as well as deductible and coinsurance See page 342 OT 232 Chapter 104

Medicare Part C “Advantage” Must be enrolled in Part B More choices, better benefits, lower costs OT 232 Chapter 105

Medicare Part D Prescription Drug Coverage Optional Requires monthly premiums Two options – Drugs only – Drugs and medical coverage OT 232 Chapter 106

Medicare Coverage & Benefits Medicare card – Provided by SS – HICN Medicare health insurance claim number 9 digits with a suffix – Figure 10.1, page 340 OT 232 Chapter 107

Medicare Claim Processing Federal gov’t does not pay Medicare claims directly!! Hires contractors to process – Fiscal intermediaries Process claims from hospitals – Carriers Process claims from physicians – Medical Administrative Contractors (MACs) Handle claims for Parts A and B Handle claims based on location OT 232 Chapter 108

Medical & Other Services Preventive Services – If covered, may still be subject to deductible – ONE routine physical exam, called the IPPE Initial Preventive Physical Exam Done within 6 months of enrolling in Plan B Screening vs. Diagnostic Services – Screenings – no symptoms – Diagnostic – has been diagnosed with a condition or has a high probability for it OT 232 Chapter 109

Excluded Services Determined by federal legislation Not covered under any circumstance vs. not medically necessary – ‘Not medically necessary’ is not normally covered unless certain conditions are met – Still must be essential and not experimental or elective OT 232 Chapter 1010

Medicare Participating Providers Optional for providers to participate in Medicare Once they do, must – accept Medicare’s allowed charge for services – submit claims on behalf of patients – receive payments directly from Medicare OT 232 Chapter 1011

Incentives 5% higher fees than for nonPAR MACs help with claims involving supplementary insurance Providers in areas with shortages of providers are eligible for 10% bonus OT 232 Chapter 1012

Payments Advance Beneficiary Notice of Noncoverage – Used when provider needs authorization to perform a service that won’t be covered by Medicare, and so will be billed to the patient – Helps beneficiaries make decisions about services that might have to be paid out-of-pocket – May be used for excluded services – Modifiers -GZ – no ABN on file, service is expected to be denied – Cannot bill patient – Emergency -GA - ABM on file, service is expected to be denied – Can bill patient -GY – service never covered, ABN not required – Patient is responsible OT 232 Chapter 1013

PQRI Physician Quality Reporting Initiative – Quality reporting program done by physicians – Optional – Bonus of 1.5% for participating – Goal? Determine best practices define measures Support improvement improve systems OT 232 Chapter 1014