Master Core Curriculum

1. Master Core Curriculum Part A Basic Module 1 Overview of Medicare

2. Agenda • Overview of Medicare • 1.5 hours

3. Learning Outcomes At the end of this module, participants will be able to: • describe enrollment processes • describe facility types and reimbursement methodology • describe entitlement and eligibility regulations/criteria • describe premiums, deductibles, and benefit periods • understand the basic difference between Part A and Part B

4. What is Medicare? • Medicare is a federal health insurance program providing medical coverage to 95 percent of the nation’s aged population and to other individuals • 42.1 million Medicare beneficiaries • 295.4 billion dollars paid in the year 2004

5. What is CMS ? • Centers for Medicare & Medicaid Services • Federal agency within the U.S. Department of Health & Human Services • Administers Medicare & Medicaid • Contracts with private insurance companies to administer the programs

6. Fiscal Intermediary (FI) Regional Home Health Intermediary (RHHI) Carrier Durable Medical Equipment Regional Carrier ( DMERC) Program Safeguard Contractor (PSC) Qualified Independent Contractor (QIC) Quality Improvement Organizations (QIO) State Agency (SA) Medicare Administrative Contractors (MAC) Medicare Contractor Terms

7. Medicare • Health Insurance for the Aged and Disabled Act (title XVIII of the Social Security Act) • Two parts • Part A - Hospital Insurance (HI) • Part B – Supplemental Medical Insurance (SMI) • Beneficiaries may elect • Part C - Medicare Advantage (MA) program • Part D – Prescription Drug Coverage

8. Medicare Eligibility Three types of Medicare beneficiaries • Aged Insured • 65 years or older • Disabled Insured • Eligible for coverage after 24 months of disability • End-Stage Renal Disease (kidney transplant or dialysis patients)/ALS patients

9. Medicare Card 9

10. Eligible for premium-free Part A when Medicare taxes paid for at least 10 years. • Premium for Part A in 2006 is $393.00 • Inpatient hospital, • Including Critical Access Hospitals (CAHs) • Inpatient Rehabilitation Hospitals (IRF)Inpatient Psychiatric Hospitals (IPF) • Long Term Care Hospital (LTCH) • Inpatient Skilled Nursing Facility (SNF) and Swingbed • Home Health • Hospice

11. Medicare Part B • Physician • Lab • Ambulance • Outpatient • Including hospitals, SNFs, home health • X-ray • Vaccine

12. Medicare Part B • Eligible individual enrolls and pays premiums • Year 2006 • Deductible: $124.00 per year • Coinsurance: 20 percent • Premium per month: $88.50

13. Medicare Part C • A set of healthcare options to give beneficiaries more choices in healthcare and contractors • Beneficiaries choose to have covered services furnished through a managed care plan, rather than through traditional Medicare • Does not include hospice care

14. Medicare Part D • Beneficiary chooses to receive prescription drug coverage • Effective January 2006

15. Inpatient Hospital & SNF Coverage • Based on benefit period • Begins with beneficiary admission to hospital/ SNF • Ends when beneficiary has not received hospital or SNF care for 60 consecutive days

16. Hospital Coverage Per Benefit Period 16

17. SNF coverage per benefit period 17

18. Inpatient Hospital & SNF Coverage Reminders • Available days do not ensure Medicare payment • Criteria must be met for coverage • Benefit days do not renew until one of the following occurs • Beneficiary out of hospital/SNF for 60 consecutive days • Beneficiary has 60 consecutive days of “non-skilled” care in a SNF/SB • Beneficiary may have multiple deductibles ($912) in one year

19. Inpatient Hospital & SNF Benefits Covered Services • Semi-private rooms • Meals • General nursing • Drugs administered during stay • Oxygen • Other services & supplies

20. Inpatient Hospital & SNF Benefits Non covered Services • Private rooms (unless medically necessary) • Take home drugs • Private duty nursing

21. Reimbursement of Hospital Benefits • Prospective Payment System (PPS) • Paid fixed dollar amount according to Diagnostic Related Group (DRG) • Hospital’s geographic location • Diagnoses/procedures • Patient’s age, sex, discharge status • Not necessarily impacted by patient’s length of stay or amount billed • Outlier payment may be made when actual charges exceed DRG formula

22. SNF Coverage Criteria • Physician certifies need for daily skilled care • Daily skilled nursing • Daily rehabilitation (therapy) services • Must require the skills of nurse or therapist • 3-day inpatient hospital stay (not including day of discharge) • SNF care related to inpatient hospital condition • Admitted within 30 days of hospital discharge • Unless medically inappropriate; AND • Medically predictable

23. Reimbursement of SNF Benefits • Skilled Nursing Facility Prospective Payment System (SNF PPS) • Paid fixed dollar amount according to Resource Utilization Group (RUG) • Determined by Minimum Data Set (MDS) • Screening status • Clinical status • Functional status

24. Outpatient Hospital Benefits • Part B benefit • Patient must have Part B for coverage • Services billed to Part A contractor (FI) • Physician’s order determines whether service provided on inpatient or outpatient basis • Some services only covered on inpatient basis • Self-administered drugs are not covered

25. Reimbursement of Outpatient Hospital Benefits Services • Provided at acute care hospital • Reimbursed under Outpatient Prospective Payment System (OPPS) • Similar services grouped into Ambulatory Payment Classifications (APCs) • Fixed amounts for each APC • Reimbursement amount • Coinsurance amount • Multiple APCs may be performed in one procedure

26. Reimbursement of Outpatient Hospital Benefits • Services provided at Critical Access Hospital (CAH) • Outpatient services are reimbursed at cost • Reference laboratory services are paid at fee schedule

27. Home Health Benefits • Services must be ordered by physician • Services must be reasonable and medically necessary • Beneficiary must be homebound • Beneficiary must need skilled care • Skilled nursing • Physical therapy • Speech therapy • Continuing occupational therapy

28. Home Health Benefits Covered Services • Intermittent skilled nursing • Part-time skilled nursing and aides • Physical, speech or occupational therapy • Medical social services • Medical supplies

29. Home Health Non-covered Services • 24-hour care • Prescription drugs • Meals • Homemaker services • Shopping, cleaning, laundry

30. Reimbursement of Home Health Benefits • Paid under Home Health Prospective Payment System (HHPPS) • Based on 60-day episode care • Amount based on Health Insurance Prospective Payment System (HIPPS) code • Determined by OASIS assessment • Clinical severity • Functional status • Service utilization • Regardless of number of visits • Exception: 4 or fewer visits, paid based on type/number of visits

31. Hospice Benefits • Physician certifies beneficiary terminally ill • Defined as 6 months or less to live if illness runs its normal course • Beneficiary elects hospice care • Sign Notice of Election (NOE) • Give up right to active treatment for terminal illness • Services provided under plan of care • Beneficiary must have Medicare Part A

32. Hospice Benefits Covered Services • Nursing, aide and homemaker services • Physical, speech and occupational therapy • Medical equipment and supplies • Social worker services • Grief counseling • Drugs for pain/ symptom control

33. Hospice Non covered Services • Curative treatment • Room and board • Services not coordinated through hospice agency

34. Reimbursement of Hospice Benefits • Paid daily rate based on level of care provided • 4 levels of care • Routine home care • Continuous home care • Inpatient respite care • General inpatient care • Hospice reimbursed for each day beneficiary on hospice, regardless of whether service provided

35. Medicare Enrollment for Institutional Providers • Must enroll to receive Medicare payments • Requires completion of the CMS-855A form • http://www.cms.hhs.gov/providers/enrollment/forms • Collects payment & general information • Secures documentation to ensure qualifications and eligibility to be a Medicare provider • Submit CMS-855A to local Fiscal Intermediary • http://www.cms/hhs/gov/providers/enrollment/contacts • FI reviews and makes recommendation to CMS RO

36. Medicare Enrollment for Institutional Providers • State Agency (SA) • http://www.cms.hhs.gov/providers/enrollment/contacts • Determines if site survey is required for your provider type • Provides information about State requirements • Conducts survey of your operations • Determines if applicable requirements for participation in Medicare is met • Determines if State requirements are met • Evaluates performance and effectiveness in providing safe and acceptable quality of care • Submits findings to CMS RO

37. Medicare Enrollment for Institutional Providers • CMS Regional Office makes final determination • Review state survey and CMS-855A results • Prepares an agreement for signature • Issues OSCAR number • 6 digit number Medicare billing number with unique identifier • Ready to submit claims to FI

38. CMS-855A • CMS-855A submission also required to request general enrollment changes • Address changes • Director/manager change • Acquisition/merger • Change of ownership • Transfer of stock • Additional location • Conversion from provider based to free standing and vice versa • Voluntary termination • Reactivation of a previously deactivated OSCAR (provider number)

39. Chapter Review Slide • What are Medicare’s four parts? • What types of individuals are eligible to receive Medicare benefits? • What two government contracted agencies must you work with to become a certified Medicare provider?

40. References CMS IOM, Pub. 100-1, Medicare General Information, Eligibility, and Entitlement • www.cms.hhs.gov/manuals/101_general/ge101index.asp Medicare Resident and New Physician Training, Overview of Medicare • www.cms.hhs.gov/medlearn/mrnp-guide.pdf Issue Paper #31, Alternative Part D Benefit Designs and Options for Enhancing Medicare Drug Coverage (January 19, 2005 • www.cms.hhs.gov/medicarereform/issuepapers/ Medicare Enrollment for Institutional Providers, CMS Publication Number 11047, September 2003 • www.cms.hhs.gov/medlearn/medenrlinstbro.pdf 2005 CMS Statistics • www.cms.hhs.gov/researchers/pubs/CMSstatistics/2005CMSstat.pdf