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Medicare the largest single medical benefits program in the United States, is a federal program authorized by Congress and administered by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA).


CMS is responsible for the operation of the Medicare program and for selecting Medicare administrative contractors (MACs) to process Medicare fee-for-service Part A, Part B, and durable medicine equipment (DME) claims. Medicare is a two part program.

Medicare program includes the following

Medicare Hospital Insurance (Medicare Part A) pays for inpatient hospital care access; skilled nursing facility stays; hospice care; and some home health care.

Medicare Program includes the following

Medicare Medical Insurance (Medicare Part B) pays for doctor's services; outpatient hospital care; durable medical equipment; and some medical services that are not covered by Part A. (sumit CMS-1500 claim for services.)

Medicare Program includes the following

Medicare Advantage (Medicare Part C), formerly called Medicare+Choice, includes managed care and private fee-for-service plans that provided contracted care to Medicare patients. Medicare Advantage is an alternative to the original Medicare plan reimbursed under Medicare Part A.

Medicare program includes the following

Medicare Prescription Drug Plans (Medicare Part D) add prescription drug coverage to the Original Medicare Savings Account Plans. (Medicare beneficiaries present a Medicare prescription drug discount card to pharmacies.)

Medicare enrollment

Medicare enrollment is handle in two ways: either individuals are enrolled automatically, or they apply for coverage. Individuals age 65 and over do not pay a monthly premium for Medicare Part A if they or a spouse paid Medicare taxes while they were working. Individuals age 65 or over and who do not pay Medicare taxes "buy in" to Medicare Part A by paying monthly premiums.

Medicare Eligibility informantion

Eligibility information is also available over the telephone, subject to conditions intented to ensure the protection of the beneficiary's privacy rights. The eligibility information that can be released by telephone is limited to that information available via EDI.

Applying for Medicare

Apply for Medicare Part A and Part B by contacting the Social Security Administration (or Railroad Retirement Board) approximately three months before the month in which they turn 65 or the 24th month of disability.

Apllying for Medicare

Upon applying for Medicare Part A and Part B, a seven-month initial enrollment period (IEP) begins that provides an opportunity for the individual to enroll in Medicare Part A and /or Part B.

Applying for Medicare

Those who wait until they actually turn 65 to apply for Medicare will cause a delay in the start of Part B coverage, because they will have to wait until the next general enrollment period (GEP), which is held January 1 through March 31 of each year. Part B coverage starts on July 1 of that year. The Part B premium is also increased by 10 percent for each 12 month period during which an individual was eligible for Part B coverage but did not participate.


Medicare pays only a portion of a patients acute care and critical access hospital (CAH) inpatient hospitalization expenses, and the patient's out-of-pocket expenses are calculated on a benefit-period basis.

Benefit period

begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.

The Term spell of illness

formely called "spell of sickness", in place of "benefit period". After 90 continuous days of 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's lifetime and are usually reserved for used during the patient's final, terminal hospital stay.

Lifetime reserve days

Persons confined to a psychiatric hospital allowed 190 lifetime reserve days instead of the 60 days allotted for a stay in an acute care hospital.

Skilled Nursing Facility Stays

Individuals who become inpatients ata skilled nursing facility after a three day minimum acute hospital stay, and who meet Medicare's qualified diagnosis and comprehensive treatment plan requirements plan requirements, pay 2010 rates of.

Hospice Care

All terminally ill patients qualify for hospice care.


is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families.

Hospice Care

This program is for patients for whom the provider can do nothing further to stop the progression of disease; the patient is treated only to relieve pain or other discomfort.

Hospice Care

Two periods of 90 days each. One 30-day period. A final lifetime extension of unlumited duration.

Respite Care

is the temporary hospitalization of a terminally ill, dependent hospice patient for the purpose of providing relief for the nonpaid person who has the major day-to-day responsibility for care of that patient.

Respite Care

A patient who is receiving hospice benefits is not eligible for Medicare Part B services except for those services that are totally unrelated to the terminal illness. When the patient chooses Medicare hospice benefits, all other Medicare benefits stop, with the exception of physician services or treatment for conditions not related to the patients terminal diagnosis.

Medicare Part B

Helps covered physician services, outpatient hospital care, and other services not covered by Medicare Part A.

Physician Fee Schedule

Since 1992 Medicare has reimbursed provider services according to a physician fee schedule (also called the Resourse-Based Relative Value Scale, RBRVS) which also limits amounts nonparticipating providers (nonPARs) can charge beneficiaries. Reimbursement under the fee schedule is based on relative value units (RVUs) that consider resources used in providing a service (physician work, practice expense, and malpractice expense).

Medicare Part C

A Medicare Medical Savings Account (MSA) Medicare pays the cost of a special healthcare policy that has a high decuctible (not exceed $6,000). Medicare also annually deposits into an account the difference between the policy costs and what Medicare pays for an average enrollee in the patient's region.

Medicare special needs plans

cove all of Medicare Part A Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases,and focused care management.

Medicare cost Plan

is a type of HMO that works in much the same way and has some of the same rules as a Medicare Advantage Plan. In a Medicare Cost Plan, if the individual receives health care from a non-network provider, the Original Medicare Plan covers the services.

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 . To be eligible, an individual must be: 55 yrs. old, or older. A resident of the service area covered by the PACE program. Able to live safely in the community. Certified as eligible for nursing home care by the appropriate state agency.


Medigap (or (Medicare Supplementary Insurance, MSI) It is designed to supplement Medicare benefits by paying for services that Medicare does not cover. Although Medicare does not pay healthcare costs,. A Medigap policy provides reimbursement for out-of-pocket costs not covered by Medicare, in addition to those that are the beneficiary's share of healthcare costs.

Medicar SELECT

is a type of Medigap insurance that requires enrollees to use a network of providers (doctors and hospitals) in order to receive full benefits.

Participating Providers

Medicare has established a participating provider (PAR) agreement in which the provider contracts to accept assignment on all claims submitted to Medicare. The number of healthcare providers signing PAR agreements with Medicare.

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