medicare is the largest medical benefits program in the US is a federal program authorized by congress and administered by the centers for medicare and medicaid services
CMS is resposible for the operation of the medicare program and for selecting medicare administrative contractors (MAC'S) to process.
medicare two part program
part A: reimburses institutional providers for inpatient , hospice, and some health services.
part B: reimburses institutional providers for outpatient services and physicians for inpatient and office services
medicare program includes
medical hospital insurance PART A :pays for inpatient hospital critical care access" skilled nursing facility stays, hospice care, and some health care.
medicare medical insurance PART B: pays for doctors, services , outpatient hospital care durable medical equipment and some medical services that are not covered by PART A.
PART B IS FOR OUTPATIENT.
medicare prescription drugs plans PART D- adds prescription drug coverage to the original medicare plan, some medicare cost plans, some medicare private fee-for-service, plans and medicare medical savings account plans
* individuals or their spouses to have worked at least 10 years in medicare-covered employment
*individuals to be the minimum of 65 years old.
*individuals to be citizens or permanenr residents of the united states
medicare part A over 65 and over
a coverage is available to individuals age 65 and over who:
*are already receiving retirement benefits from social security or the railroad retirement board (RRB)
*are eligible to receive social security or railroad benefits but have not yet filed for them.
*had medicare-covered goverment employment
medicare part A 65 and under
a coverage is available to individuals under age 65 who have
*received social security or RRB disability benefits for 24 months.
*end -stage disease and meet certain requirements.
* to obtain medicare eligibility information is throught electronic data interchange (EDI)
*eligibility information is also available over the telephone, subject to conditions intended to ensure the protection of the beneficiarys privacy rights. the eligibility information can be released by telephone is limited to that information available via EDI.
individuals age 65 and over do not pay monthly premium for medicare part A if they or a spouse paid medicare taxes while they were working. individuals age 65 and over who do not pay medicare taxes "buy in" to medicare part A by paying monthly premiums
applying to medicare
must apply for medicare part A and B by contacting the social security administration approximately three months before they turn 65 or the 24th of the disability (before they turn 65)
PRIVACY ACT 1974
the privacy act of 1974 prohibits release of information unless all the listed required information is accurately provided
medicare pays for a portion of a patients acute care and critical access hospital CAH patient hospitalization expenses, and the patients out of pocket expenses are calculated on a benefit-period basis.
begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.
spell of illness
some medicare literature uses the term SPELL OF ILLNESS formely called SPELL OF SICKENESS.
*After 90 days continous hospitalization the patient may elect to use some or all of the allotted lifetime reserve days, or pay the full daily charges for hospitalization
lifetime reserve days
60 days may be used only once during a patient lifetime and are usually reserved during for the use during the patients final, terminal hospital stay
is for terminally ill patients
4 benefit period that have to do with hospice care
two periods of 90 days each
one 30 day period
a final LIFETIME extension of unlimited duration
is temporary hospitalization for termianlly ill patients dependent hospice patient for the purpose of providing relief for nonpaid person who has the major day to day responsibility for care of that patient
medicare part B
helps cover physician services , outopatient care and other services not covered by medicare part A including physical and occupational
physician fee schedule
also called the resource-based relative value scale RBRVS limits the amount for nonparticipating providers
* reimbursement under the fee schedule is based on relative units RVUs that consider resources used in providing a service.
medicare special needs
cover all medicare PART A and Part b health care for individuals who can benefit tha most from special care for chronic illness etc.
MEDICRE PART D DRUGS
offer prescription coverage to all medicare beneficiaries that may help lower prescription drug costs and help protect against higher costs
is a type of HMO that works in much the sme way and has some of the same rules as medicare advantage plan
a demostration pilot/ program
is a special project that tests improvements in medicare coverage, payment and quality of care, usually apply to a specific group of people and or offered only in specific areas
programs of all inclusive care for the elderly PACE
combine medical,social, and long term care services for frail people who live and receive health care in the community
medigap(or medicare supplementary insurance MSI
is offered by commercial health insurance companies and some BCBS it is designed to supplement medicare benefits by paying for services that MEDICARE does not pay for