Terms in this set (38)
What is Medicare?
a federal program which provides health insurance benefits for people who meet 1 of 3 categories:
- 65 or older
- those with end stage renal disease (ESRD)
- those under 65 with certain disabilities
Who is the Medicaid administration?
Centers for Medicare & Medicaid Services (CMS)
- CMS is an agency within the Department of Health and Human Services (HHS)
- contractor with CMS and process 20% of claims
What established both Medicare and Medicaid programs?
The Social Security Act of 1965
- signed by LBJ
How does Medicare work?
- "fee-for-service" system, where beneficiary is charged a fee for each health care service/supply received
- beneficiaries can see any provider that is approved by the medicare program
What are the 4 parts of medicare?
- Part A: Hospital Insurance
- Part B: Medical Insurance (Dr. and outpatient care)
- Part C: Medicare Advantage
- PArt D: Medicare Rx Drug Coverage
What does original Medicare include?
Hospital coverage under Pt. A and medical coverage under Pt. B.
- both hospital and medical coverage can be obtained through private insurance companies under Pt. C
Outpatient Rx drug coverage can be obtain through?
Medicare Pt. D
- through private insurance companies
What do standard Medicare options include?
Original Medicare (Part A and Part B)
- operated by gov't and gov't subcontractors
Medicare Advantage (Part C)
- operated by private companies approved by Medicare
- combine hospital costs, doctor, and outpatient care in one plan
What do additional Medicare options include?
- helps pay for Rx drugs in original Medicare
- available in Medicare Advantage plans
What do possible Medicare options include?
Medicare supplement insurance plans
- cover some costs not covered in Part A & B
Additional benefits for Part C
- often included, such as vision and hearing services
What is eligibility for Medicare Part A based on?
work history, citizenship, and age
- aged uninsured individuals must pay a monthly premium
disabled who receives social security checks
End Stage Renal Disease (ESRD)
What is eligibility for Medicare Part B based on
- voluntary program which requires the payment of a monthly premium
"Hold harmless" provision
- protection of the rise of premium
- can receive eligibility on an adjusted monthly premium
How is Medicare financed?
- Payroll taxes
- Beneficiary cost sharing (deductibles and coinsurance)
- general federal government revenues
What services does Part B cover?
- medically necessary services to treat a disease or condition
- preventative care to prevent illness
What is Part B cost sharing?
beneficiaries of Part B share the cost of services by paying:
- deducible: yearly payment
- "assignment" & balance billing: percentage of the total cost that is assigned
What is Medicare Part C?
Managed care plans
- offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits
- can provide additional benefits including eye and oral coverage
What is Medicare Part D?
Rx drug plans
Standard benefit design
- designed to provide drug coverage through a complex cost sharing structure
Medication Therapy Management Services (MTMs)
- required to be included in Part D coverage
What is the spending by type of service provided by Medicare?
Parts A and B are more expensive than Parts C and D
- A > B > C > D
Who is automatically enrolled for Medicare?
Those receiving SS benefits or Railroad Retirement Board benefits
When should the initial enrollment period package be mailed?
3 months before
- 25th month of disability benefits
- Age 65 (don't have to be retired)
Who needs to sign up for Medicare?
Those who are not automatically enrolled
When should the Medicare Card by kept?
if you are accepting Medicare Part A and B
When should the Medicare Card be returned?
When you are refusing Part B
Who funds Part A?
Funded by the federal gov't through social security payroll tax deductions
Medicare Part A premium
Most receive Part A premium free
- if FICA taxes have been payed for at least 10 years
- can pay premium if payed FICA taxes for less than 10 years
- may receive penalty if not bought when first eligible
What does Medicare Part A cover?
Inpatient Hospital Stays
Skilled Nursing Facility Care
Home Health Care Services
Medicare Part B premium
- individuals must enroll in and pay a Part B premium
- premiums usually go up each year and are higher for individuals with higher incomes
- federal gov't funds Part B costs through the general tax revenues; beneficiary premiums cover 25% for Part B expenses income in 2013
How can the Part B premium be paid for?
Deducted monthly from
- social security
- railroad retirement benefit
- federal retirement payment
If not deducted
- billed every 3 months
- medicare Easy Pay to deduct from band account
What is the Part B Late Enrollment Penalty
Penalty for not signing up when first eligible
- 10% more for each 12-month period
- may have penalty as long as you have Part B
SIgn up during a Special Enrollment Period (SEP)
- Usually no penalty
What does Medicare Part B cover?
- Doctors' services
- Outpatient Medical & Surgical Services and Supplies
- Home Health Care Services
- Durable Medical Equipment
- Other services
What are some Part B covered preventive services?
- One-time "Welcome to Medicare" physical exam
- Annual wellness visit after 12 mos. enrolled in Part B
- Immunizations - pneumococcal, hepatitis B, annual flu shot, H1N1
- Abdominal aortic aneurysm screening - one time, with referral
- Bone mass measurement - every 24 months for certain conditions
- Cardiovascular screening blood tests - every five years for all persons
- Colorectal cancer screening - four different tests, vary in frequency
- Diabetes screenings - up to two per year for those with risk factors
- EKG screening - one time, with referral
- Glaucoma testing - once per year for those at high risk
- HIV screening
- Mammogram - annual screening for most women
- Pap test and pelvic exam - every 24 months
- Prostate cancer screening - every 12 months for men over age 50
- Smoking cessation counseling
What are some services NOT covered by Part A and Part B?
- Dental care/dentures
- Cosmetic surgery
- Custodial care
- Health care while traveling outside the U.S.
- Hearing aids
- Orthopedic shoes
- Outpatient prescription drugs (covered under Part D)
- Routine foot care
- Routine eye care and eyeglasses
- Vaccines, except as previous listed (covered under Part D)
What is Original Medicare?
Health care option run by the Federal gov't
- provides Part A and/or Part B coverage
- can see any doctor that accepts Medicare
- can join a Part D plan to add drug coverage
- Can join a Medigap plan to pick up the "gap"
What do beneficiaries pay for original Medicare?
- Part B premium (Part A free for most people)
- Deductibles, coinsurance, or copayments
Who can accept an medicare assignment?
Doctors, providers, or suppliers
What is an assignment?
A signed agreement with Medicaid (can also be required by law), where doctors, providers, or suppliers accept the medicare-approved amount as full payment for covered services.
- only charge medicare deductible/coinsurance amount for services
What is the limiting charge for suppliers who do not accept a medicare assignment?
- can add up to 15% to medicare-approved amount, but not more than that
What are some examples of suppliers who must accept a medicare assignment?
- medicare Pt. B - covered rx drugs
- ambulance suppliers
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