Medicare Flashcards
What is the history of medicare?
Signed into law in 1965 by president Johnson to provide health and economic security to seniors
Expanded to cover younger adults with permanent disabilities in 1972
How many individuals were covered by medicare in 2020?
60 million people
Including 7 million under 65 years that are disabled
What does medicare do?
Covers individuals without regard to income or medical history
Helps pay for range of medical services, including inpatient hospital, physician, home health, diagnostic tests and prescription drugs
What is medicare?
A federal health insurance program that covers 60 million Americans
It serves eligible beneficiaries without regard to income or medical history
Who is eligible for medicare?
Individuals ages 65 and over (automatically entitled to Part A)
Individuals under 65 years who receive social security cash payments due to a disability (generally eligible for medicare after a 2 year waiting period)
People with end-stage renal disease or ALS (entitled to Part A regardless of age)
What is medicare part B?
Supplementary medical insurance
Voluntary
Covers 95% of all Part A beneficiaries
How many parts does medicare have?
4 (A, B, C, and D)
Each covers different benefits
What is medicare part A?
Hospital insurance program
Services: inpatient hospital, skilled nursing facilities, home healthcare services, and hospice
Funded by a 2.9% tax on earnings paid by employers and workers
No premiums, but recipients pay co-pays and deductibles
Accounts for 40% of medicare costs
What is medicare part B?
Supplementary medical insurance
Services: physician, outpatient services, home health, preventative services
Funded by general and recipient premiums ranging $96.40 to $308.30
Voluntary program
27% of medicare spending
Who is eligible for medicare part A? How much does it cost to the recipient?
Individuals (and spouses) entitled to Part A after paying payroll taxes for 10+ years
$1,632 deductible for hospital inpatient in 2024
Who is eligible for medicare part B? How much does it cost to the recipient?
Virtually all beneficiaries entitled to Part A are enrolled in Part B
$174.00 monthly premium in 2024
Beneficiaries with relatively high incomes (about $85,000 for individuals) pay a higher income-related premium, while those with very low incomes do not pay the premium if they qualify for Medicaid
$240 deductible; 20% coinsurance for physician visits and outpatient hospital services
What is medicare part C?
Medicare advantage
Health plan options approved by Medicare and administered by private insurance companies
Plans include all the benefits of original Medicare and more like prescription drug coverage and annual physical exams
Recipients pay premiums
21% of Medicare spending
Lower cost-sharing, many times there is no copayments or coinsurance
Can beneficiaries of medicare part C choose to enroll in a regular fee-for-service program or a medicare advantage (MA) plan?
Yes
MA include HMOs, PPOs and other private health plans
Some plans offer extra benefits and have lower cost-sharing requirements than traditional Medicare
Access to doctors and other health care providers is typically limited to those in the plan’s network (may contribute to longer wait times)
Premiums are lower than part B
Are medicare part C plans paid a fixed amount per enrollee?
Yes
On average, 14 percent more than it would pay under traditional Medicare
This extra payment will increase overall costs to Medicare by about~$150 b over 10 years
What is medicare part D?
Prescription drug benefit
Two options available: prescription drug coverage as part of a medicare advantage plan and a stand-alone prescription drug plan in addition to your existing original medicare coverage (referred to a PDP plans)
11% of medicare spending
No PDP may have a 2024 medicare deductible of more than $400
Is there cost-sharing and benefit gaps in medicare?
Yes
It doesn’t cover all medical benefits (very limited in terms of long-term care coverage; no dental, hearing aids, or eyeglasses)
Has relatively high cost-sharing requirements (deductibles for part A, B, and D; coinsurance/copayments)
Part D coverage gap (they’ll pay up to a certain amount, and then you pay 100% up to the next level - deductible moved to the middle)
No limit on out-of-pocket spending (unlike typical plans offered by a large employer)
Pays about half of beneficiaries’ total long-term care spending (leads to a long-term care crisis)
What is the part A trust fund financial challenge?
The hospital insurance trust fund is projected to be insolvent by 2031 – with insufficient funds to pay for all promised benefits
The number of workers per beneficiary is projected to decline as the Medicare population grows in the future
What is the GDP financial challenge?
Medicare spending is projected to go from 3.1% of GDP in 2021 to 3.9% of GDP by 2032
The Congressional Budget Office indicates most of the growth is due to rising health costs, rather than the aging of the Baby Boom generation
What is medigap coverage?
Medicare supplemental insurance policy
Offered by private companies to assist in paying for healthcare expenses that are not covered by Original Medicare (Part A and Part B)
You must have Medicare Part A and Part B if you want to purchase a supplemental Medigap policy
What are medicare administrator contractors?
Fiscal intermediaries
The Medicare program is administered locally to providers and beneficiaries by private entities, usually health insurance companies(e.g., a Blue Cross Blue Shield plan) that contract with CMS
There are 15 MACs
What is local coverage determinations?
Established by MACs
For selected services so that providers better understand what services are covered and how to code and document the procedures
LCDs reproduce coverage rules from national Medicare policy manuals and provide rules in the absence of a national policy or for further clarification of a national policy
Varies from region to region
What must audiologists bill when performing diagnostic testing of a medicare beneficiaries?
Must bill medicare directly
These services cannot be billed “incident to” a physician, because they are a defined benefit for audiologists
The NPI of the audiologist must be listed on the claim as the rendering provider of the services
Do audiologists have an opt-out provision in their definition that allows private contracts with medicare beneficiaries?
No, you must bill medicare
What does medicare cover for audiologic care?
Medicare doesn’t cover routine hearing exams, hearing aids, or exams for fitting hearing aids
It will cover certain diagnostic hearing tests
If you qualify for a diagnostic hearing test under Original Medicare, you will still pay the Part B deductible plus 20% of the test
Does medigap cover hearing aids?
Usually not
If you have Medigap plan C, it will cover 100% of your Medicare Part B deductible and it will pay 100% of the hearing diagnostic test’s coinsurance
In this case patients would not pay anything for the diagnostic test
Do medicare advantage plans cover the cost of hearing aids and diagnostic tests?
May cover some of the cost
Most do not
MA plans are not standardized so each plan can decide if they want to cover some or none of the cost of hearing aids
