Chapter 14 MEDICARE

the largest single medical benefits program in the United states.
its a federal program authorized by Congress and administered by the centers for Medicare and medicaid Services.
responsible for the operation of the Medicare program and for selecting medicare administrative contractors (MAC's) to process Medicare fee for service, Part A, Part B and durable medicine equipment, DME claims.
Medicare hospital insurance (Part A)
pays for inpatient hospitla critical care access; skilled nursing facility stays; hospice care; and some home health care.
Medicare hospital insurance (Part B)
pays for doctors services; outpatient hospital care, durable medical equipment and some medical service that are not covered by Part A.
Part B
is for outpatient only
Medicare Prescription Drug plans (Part D)
add prescription drug coverage to the Original medicare plan, some medicare cost plans, some medicare private fee for service plans and medical savings account plans.
General medicare eligibility requires:
1. individuals or their spouses to have worked at least 10 years in medicare covered employment
2. individuals to be the minimum of 65 years old.
3. individuals to be citizens or permanent residents of the united states.
Eligibility informations is....
available over the telephone, subject to conditions intended to ensure the protection of the beneficiarys privacy rights.
The Privacy Act of 1974
prohibits release of information unless all the listed required information is accurately provided.
Medicare enrollment handled in two ways
1. automatically or
2. they apply for coverage.
Medicare Enrollment
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. Those who didn't pay medicare taxes "buy in" to medicare part A by paying monthly premiums.
Applying for Medicare
a 7 month initial enrollment period (IEP) (before they turn 65), begins that provides the an opportunity for the individual to enroll in Medicare part A and/or Part B.
General Enrollement period
held every Jan. 1st through March 31 of each year. is for those individuals that wait until they reach age 65 causing a delay in the start of part B of the coverage.
benefit period
begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.
Medicare literature - "spell of illness"
formerly called "spell of sickness", in place of benefit period.
lifetime reserve days
60 days - may be used only once during a pt's lifetime and are usually reserved for use during the pt's final, terminal hospital stay.
persons confined to a psychiatric hospital
are allowed 190 lifetime reserve days instead of the 60 days allotted for a stay in an acute care hospital.
hospice care
all terminally ill pts' qualify for this.
is an autonomous centrally adminstered program of coordinated inpatient and outpatient palliative services (relieve of symptoms) for terminally ill pts' and their families.
hospice care
this program is for pts' for whom the provider can do nothing fruther to stop the progression of disease, the pt is treated only to relieve pain or other discomfort.
medicare limits hospice care to 4 benefit periods:
1. two periods of 90 days each
2. one 30 day period.
3. a final lifetime extension of unlimited duration.
respite care
is the temporary hospitalization of a terminally ill, dependent hospice pt for the purpose of providing relief for the nonpaid person who has the major day to day responsibility for care of that pt.
When a pt chooses Medicare hospice benefits:
all other medicare benefits stop, with the exception of physician services or treatment for conditions not related to the pt's terminal diagnosis.
Medicare Part B
helps cover physician services, outpatient hospital care, and other services not covered by part A including physical and occupational therapy and some health care for pts who do not have medicare part A.
physician fee schedule
also called the resource based relative value scale, (RBRVS)
physician fee schedule
has reimbursed provider services according to this schedule and the "physician billing schedule" and also has limits amounts nonparticipating providers can charge beneficiaries.
Reimbursement under the fee scheduled...
is based on relative value units (RVU's) that consider resources used in providing a service, such as (physician work, practice expense and malpractice expense).
Medicare Part C
also known as Medicare Advantage Plans, are health plan options that are approved by Medicare but managed by private companies.
Medicare Advantage plans
provide all medicare Part A (hospital) and Medical part B (medical) coverage and must cover medically necessary services.
Medicare Medical Savings Account (MSA)
is used by an enrollee to pay healthcare bills, while Medicare pays the cost of a special healthcare policy that has a high deductible (not to exceed $6000)
The money deposited annually by Medicare into an MSA
is managed by a Medicare approved insurance company or qualified company. it is not taxed if the enrollee uses it to pay qualified healthcare expenses.
Medicare special needs plans
cover all Medicare part A & 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 part D
Medicare Prescription Drug Plans offer prescription drug coverage to all medicare beneficiaries that mya help lower prescription drug costs and help protect against higher costs in the future.
Medicare part D
individuals who join a medicare drug plan pay a monthly premium
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 this type of plan if an individual receives health care from a non-network provider, the original Medicare Plan covers the services.
Demonstration/Pilot program
is a special project that tests improvements in medicare coverage, payment and quality of care.
usually apply to a group of people and or are offered only in specific areas.
Programs of all inclusive care for the Elderly (PACE)