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Review. Medicare. Never intended to pay 100% of health care costs There are coverage gaps For people 65+ and under 65 with a disability 4 parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Plans

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  • Never intended to pay 100% of health care costs
    • There are coverage gaps
  • For people 65+ and under 65 with a disability
  • 4 parts of Medicare
    • Part A: Hospital Insurance
    • Part B: Medical Insurance
    • Part C: Medicare Advantage Plans
    • Part D: Prescription Drug Coverage
  • Part A & B called Original Medicare
medicare part a hospital insurance
Medicare Part A (Hospital Insurance)
  • Part A Covers:
    • Inpatient hospital care
    • Care in a skilled nursing facility (SNF)
    • Home health care
    • Hospice care
    • Blood
skilled nursing facility snf coverage
Skilled Nursing Facility (SNF) Coverage
  • Must be a Medicare participating facility
  • Physician must certify that patients needs and receives daily skilled care from RN or therapist
  • Prior in-patient hospital stay of 3 days or more (72 hours as an admitted patient)
    • An overnight stay doesn’t always mean an in-patient day (can be observation day)
    • Break in skilled care that lasts more than 30 days will require a new 3 day hospital stay to qualify for additional SNF care
  • Admitted to SNF within 30 days of discharge from hospital
medicare part b medical insurance
Medicare Part B (Medical Insurance)

Physicians’ Services

Out-patient hospital services

Durable medical equipment

Prosthetics, orthotics, and supplies


Home health care (if not Part A)

Blood (if not Part A)

medicare part b important terms
Medicare Part B: Important Terms

Medicare approved amount: Fee Medicare sets for Medicare covered service

Excess charges: Amount owed by beneficiary above the Medicare approved amount. In other states, there is a limit on excess charges of 15%

Ban on Balanced Billing: Massachusetts has a law prohibiting excess charges by physicians

Accepting Assignment: Accepting the Medicare approved amount as payment in full

Participating Provider: Signing an agreement saying you agree to accept assignment for all beneficiaries in all cases (non-participating – less important in MA)

examples of gaps in medicare
Examples of Gaps in Medicare
  • Part A gaps:
    • In-patient hospital deductible
    • Daily co-payment for in-patient hospital days 61-90
    • Daily co-payment for in-patient hospital days 91-150
    • Daily co-payment for SNF days 21-100
  • Part B gaps:
    • Annual deductible
    • Co-insurance (usually 20%)
  • First three pints of blood
  • Coverage outside the United States
medicare advantage
Medicare Advantage
  • Option for supplementing Original Medicare
    • Offered by a private company that contracts with Medicare to provide a beneficiary with their Part A & B benefits
    • The plan must offer Part D drug coverage – members who want drug coverage may onlytake drug plan offered by the Medicare Advantage plan
      • If enroll in a stand alone PDP, will be dis-enrolled from Part C and returned to Original Medicare
  • Different plan types available
  • Automatic disenrollment when changing MA plans
quick reference pro s of medicare advantage plans
Quick Reference:Pro’s of Medicare Advantage Plans
  • Medicare Advantage Plans tend to attract people who are not high utilizers of medical services. They also attract people who want a lower premium plan
  • Pro’s:
    • Convenience of having only one plan (drug plan can be included)
    • More choices available (HMO’s, PPO’s…)
    • Lower premiums than Medigap plans
    • Potential for better coordination of care (HMO’s provide this)
    • Additional benefits such as hearing, dental, vision and annual exams
  • Option for supplementing Original Medicare
    • Offers coverage to fill gaps in Original Medicare
    • Offered by private insurance companies, not the federal government
    • Prescription coverage NOT included; if a beneficiary wants prescription drug coverage, they must join a Medicare Prescription Drug Plan
  • Must call plan to dis-enroll when changing Medigap plans
    • Not automatic disenrollment like with Medicare Advantage
    • Medigap= Private companies that don’t communicate
quick reference pro s of medigap policies
Quick Reference:Pro’s of Medigap Policies
  • Medigap policies tend to be bought by people with a high utilization of medical services such as doctors and hospital services. These policies are also popular amongst individuals who travel in foreign countries and who like to be able to choose which doctor they see without a referral
  • Pro’s:
    • Can see any provider that accepts Medicare (no networks)
    • No referrals or PCP is needed
    • Continuous open enrollment periods
    • Low to no co-pays or deductibles
    • Many policies offer travel coverage
    • All policies standard; only 2 types of policies so choosing policy is easier
    • ESRD 65+ can join a Medigap policy
part d
Part D
  • Must have Part A and/or Part B to be eligible
  • 2 ways to get prescription coverage:

1.Medicare Prescription Drug Plans (PDPs); also known as stand alone plans

2. Medicare Advantage (Part C) Plans with drug coverage (MA-PD’s)

  • Part D is voluntary, but eligible beneficiaries who do not enroll may be subject to a penalty
    • Must have “creditable coverage” to avoid penalty
part d1
Part D
  • Plans can differ on many levels but must meet both pharmacy access and formulary standards set by CMS
  • Formulary= List of “covered drugs” in the prescription benefit
    • Each plan must include and cover certain drugs or certain classes of drugs
  • 4 Enrollment Periods
    • Initial: Same as Part B (7 months around birthday)
    • Open: Oct 15th- Dec 7th, coverage effective Jan 1st
    • Special: Various qualifying events
    • MADP: Jan 1st– Feb 14thduring which beneficiary can:
      • Dis-enroll from MA plan and return to original Medicare and enroll in a stand-alone Medicare Prescription Drug Plan (PDP)
      • Dis-enroll from MA plan without drug coverage and enroll in a PDP
extra help
Extra Help
  • Federal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part D
  • Extra Help subsidizes:
    • Premiums
    • Deductibles
    • Copayments
    • Coverage Gap “Donut Hole”
    • Late Enrollment Penalty
  • Does NOT subsidize non-formulary or excluded medications
  • Apply through Social Security Administration
extra help1
Extra Help
  • Full Extra Help
      • 135% of the Federal Poverty Level (FPL) and asset limits
      • Full premium assistance with no deductible
      • Low, capped co-payments. Could be $0 for some generics at any level
      • Partial Extra Help
        • 150% of the FPL and asset limits
        • Reduced premiums (sliding scale – between 25% -75% assistance dependent upon income)
        • Reduced deductible and 15% copayments
prescription advantage
Prescription Advantage
  • Massachusetts’ State Pharmacy Assistance Program (SPAP)
  • Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i.e. retiree plan)
  • Provides primary prescription coverage for those who don’t qualify for Medicare
  • Benefits are based on a sliding income scale only– no asset limit!
  • Level of assistance provided is determined by gross income
  • Different income limits for under 65 and 65 and over
  • Members are provided a SEP (one extra time each year outside of open enrollment to enroll or switch plans)
claims processing
Claims Processing
  • Medicare processes over 3 million claims daily for over 39 million beneficiaries
  • Providers required to process claims directly to Medicare
    • Medicare pays for services under the Prospective Payment System where providers are paid a fixed amount based on payment categories
  • Medicare Administrative Contractors (MAC’s)
    • Private companies that contract with Medicare to process Part A & B claims, investigate fraud & abuse, mail Medicare Summary Notices, provide beneficiary customary services
medicare summary notice msn
Medicare Summary Notice (MSN)
  • Medicare beneficiaries will receive a Medicare Summary Notice (MSN) on a quarterly basis
    • This is a statement, not a bill
  • The MSN details:
    • Part A and Part B inpatient and outpatient claims processed during the period
    • Dates of service
    • Amount billed and paid to the provider and other vital information
  • Beneficiaries shouldn’t pay providers until MSN is received to match provider bill with beneficiary’s record
medicare approved amount
Medicare Approved Amount

Medicare decides amount is reasonable for a particular covered service

Adjusted geographically

These are paid after the A & B deductibles are met

Medicare Part B pays 80% of the Medicare approved amount for most services after the beneficiary has met the annual deductible

non participating providers
Non-participating Providers
  • Providers can opt to accept assignment or not accept on a case-by-case decision
  • Medicare only pays for durable medical equipment (DME) purchased from a participating provider
  • If provider does not accept assignment:
    • Provider is not accepting the Medicare approved amount
    • Beneficiary may be required to pay up front and file a claim with Medicare or other insurers
    • Beneficiary must pay the difference between retail price and Medicare approved amount
    • Provider must still bill Medicare
medicare and masshealth
Medicare and MassHealth

Doctors and most providers must accept assignment for beneficiaries who are on MassHealthAND Medicare

limiting charge
Limiting Charge

Non-participating doctors can charge up to 115% of the Medicare approved amount

Does NOT apply to Durable Medical Equipment


massachusetts ban on balance billing law
Massachusetts Ban On Balance Billing Law
  • Prohibits doctors licensed in Massachusetts from billing Medicare beneficiaries for more than the Medicare approved amount
    • Applies only to services provided in Massachusetts
  • Massachusetts doctors who are “non-participating providers” and work in other states may charge a patient up to 15% above the Medicare approved amount
    • These are called legitimate excess charges
  • Some other states that limit Medicare charges include Connecticut, Rhode Island, Vermont and New York
billing medicare
Billing Medicare

Federal Law mandates all providers who furnish services and products to Medicare beneficiaries submit claims to Medicare

Also applies to beneficiaries who pay up front

crossover billing
Crossover Billing

Participating providers, Medicare contractors, Medigap insurers and most other private insurers participate in crossover billing for Medicare beneficiaries who assign both Medicare and Medigap payments to their providers

After the Medicare portion of the claim has been processed, Medicare forwards the balance of the claim to the Medigap insurer or other insurer for payment of covered amounts

For crossover to work, the Medicare beneficiary must provide complete and accurate information to all their Medicare providers about their other health insurance coverage, including their Medigap policy

medicare as secondary payer
Medicare as Secondary Payer
  • Medicare is the primary payer for most beneficiaries with Medicare supplement insurance policies
  • In general, Medicare is the secondary payer for Medicare covered services if the beneficiary is also covered by any of the following:
    • Motor vehicle or liability insurance
    • Employer group insurance
    • Public Health Service
    • Indian Health Service
    • Workers’ Compensation
    • Black Lung Program
medicare patient rights
Medicare Patient Rights
  • The right to receive easy-to-understand information about Medicare including info on costs, payments, how to file an appeal
    • The right to file appeals and grievances
    • The right to know all treatment options from the health care provider in language that is understandable and clear to the beneficiary
    • The right to emergency care without prior approval anywhere in the United States
    • The right to have personal information that Medicare collects kept private
medicare fraud abuse
Medicare Fraud & Abuse
  • Fraud
    • The intentional deception or misrepresentation that an individual makes knowing that it could result in an unauthorized benefit
  • Abuse
    • The unintentional practice or procedure inconsistent with sound medical, business or fiscal practice resulting in a provider receiving payment that fail to meet recognized standards of care or incur unnecessary costs
utilization review committee urc
Utilization Review Committee (URC)
  • The URC continually reviews patients’ stays in hospitals and skilled nursing facilities
  • URC works within facilities and is comprised of doctors or professionals not related to the patients involved
  • Each admitted person’s doctor must satisfy the URC that the patient meets the admission criteria and continues to need an acute hospital level of care
  • A URC has the authority to terminate Medicare’s obligation to pay for medical services in a hospital or skilled nursing facility
    • It is the URC that determines that it’s time to be discharged
    • If a patient disagrees, s/he may appeal
hospital skilled nursing facility discharge patient rights
Hospital/Skilled Nursing Facility Discharge Patient Rights
  • Hospitals are required to deliver the Important Message from Medicare (IM), to all Medicare beneficiaries (Original Medicare & MA beneficiaries) who are hospital inpatients which informs them of their hospital discharge appeal rights
  • To appeal a proposed discharge, beneficiary should call MassPROand request an immediate review of the notice
    • MassPRO is the Quality Improvement Organization [QIO]; an organization of doctors and nurses who contract with Medicare to review hospital discharge decisions
    • The MassPro helpline is available 24 hours a day, 7 days a week, including holidays
where to go for help appeals grievances
Where to go for Help: Appeals & Grievances
  • MAP (Massachusetts Medicare Advocacy Project)
    • Provides free advice and legal representation for Massachusetts Medicare beneficiaries
    • (866) 778-0939 or (800) 323-3205
  • MassPro (Massachusetts Peer Review Organization)
    • Group of practicing doctors and other health care professionals paid by the federal government to review and monitor quality of care given to Medicare beneficiaries
    • Processes quality of care complaints and grievances and some hospital appeals
    • (800) 252-5533;