Medicare

Medicare is a federal health insurance program that provides health insurance coverage for members, called beneficiaries. Medicare applies to beneficiaries who are 65 or older and are citizens or permanent residents of the United States, certain younger people with disabilities or anyone who has end stage renal disease.

Medicare beneficiaries may receive:

1.      Medicare Part A - Hospital coverage that pays for hospital services, skilled nursing facilities, home health and hospice care. There is no cost to most beneficiaries. It is based on years in the work force.

2.      Medicare Part B - Medical, professional or traditional coverage as it pays for doctor’s services, outpatient therapy, durable medical equipment, supplies and other needed services. Monthly premium payment is required.

3.      Medicare Part C - Part of Medicare Part B. It is not really a separate coverage rather it allows for beneficiaries to select a managed care plan instead of a traditional 80/20 plan.

4.      Medicare Part D Prescription Drug - This provides coverage for prescription drugs. This coverage is optional and requires payment of an additional premium.

Medicare Enrollment

Once you are approaching age 65, you will have a 7 month enrollment period in which to enroll for Medicare coverage. You have up to 3 months prior to the month of your birth, the month of your birth, up until 3 months after in which to enroll. If you miss this period, you will have to wait until the next scheduled open enrollment period.

Disabled persons are eligible to enroll for Medicare once they have been on SSI for 24 months.

After enrollment is completed, the beneficiary will receive a Red, White and Blue ID card. The beneficiary’s ID number is their 9-digit social security number, plus a one or two-digit suffix (added to back of the ID number, ex. 123456789A). A description of some of these suffixes is described below:

1.      A    WAGE EARNER

2.      D   AGED WIDOW

3.      B   AGED WIFE

4.      D4   REMARRIED WIDOW

5.      B1   HUSBAND

6.      E     MOTHER (WIDOW)

7.      C1   CHILDREN

8.      F1    FATHER

9.      F2   MOTHER

Note:  In keeping with the HIPAA requirement that all patient's PHI -protected health information must be kept secure, the Social Security number listed on all Medicare ID cards must be replaced with encrypted number before 2019. 

At the time of enrollment, the enrollee must select either a traditional Medicare plan, which is a 80/20 plan or they can select a Medicare managed care plan with a wide range of coverage's and benefits.

Because of these two different paths, we have a tendency to separate Medicare into those categories - Traditional Medicare and Medicare Managed Care. The benefits, processes, rules and procedures differ greatly between the two.

Medicare Managed Care vs. Medicare Traditional

  • Medicare Traditional plans, normally, do not require preapproval or preauthorization for certain medical services and surgery. Medicare coverage policies are located online and they provide full details on the procedures, parameters for coverage, the associated codes, etc. As long as the patient fits the criteria for coverage they can proceed.
  • Medicare Managed care plans usually require some level of preapproval or preauthorization for certain medical services and surgery.
  •  Medicare traditional plan will be reimbursed based on the Medicare Fee Schedule. This fee schedule provides the reimbursement amounts for just about every service, treatment or supply making is easy for a beneficiary to have some general idea of what, if any, costs they can expect to incur.
  • Medicare Managed care plans can be reimbursed under the Medicare Fee Schedule, by contracted rate, capitation or any other type of methodology.  
  • Traditional Medicare plans pay 80% of allowed. The beneficiary is responsible for the 20% or it can be billed to a Medigap plan.
  • Medicare Managed care plans could have a host of different plans and benefits. The managed care plan must provide the same level of coverage that would be available under the traditional plan or better.
  • Providers that participate with Medicare traditional plans, agree to accept the Medicare assignment. This means that they agree to accept the Medicare allowed amount and can only bill the patient for any applicable coinsurance or deductible.
  • Providers that opt out or chose not to participate with Medicare can only collect up to 115% of the limiting charge plus 20% as well as any applicable deductible.
  • All providers are required, by law, to submit claims for Medicare Beneficiaries and they cannot bill the patient for a claim filing fee.

Medicare does not pay for:

  • Custodial care
  • Nursing home care
  • Full-time nursing care in the home
  • Dental care and dentures
  • Most eyeglasses and eye exams or routine physical exams/checkups (except screening Pap smears and screening mammograms)
  • Most immunization shots (except the pneumonia vaccine, flu vaccine and Hepatitis B vaccine)
  • Over-the-counter drugs
  • Routine foot care
  • Hearing aids or the tests associated with them
  • Private duty nurses
  • Extra charges for a private room
  • Personal comfort items
  • Cosmetic surgery
  • Any chiropractic service, except for treatment of subluxation of the spine and services considered not reasonable and necessary.

 Source: www.cms.gov


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