UNIT 20 Flashcards
MEDICARE
Medicare pays a large portion of the health care bill for persons who:
- are age 65 or over
- have end-stage renal disease (kidney failure)
- have been receiving Social Security disability benefits for at least 24 months
FULLY INSURED
In order to be covered by Medicare, an individual must be “fully insured” according to Social Security. Qualification requires accumulating at least 40 credits, which are earned by generating a minimum amount of work-related income over at least the past 10 years and paying Social Security (FICA) taxes.
MEDICARE ENROLLMENT
The initial enrollment for Medicare is a 7 month period that begins 3 months BEFORE the month and individual turns 65 , includes the month they turn 65, and ends 3 months AFTER the month they turn 65.
MEDICARE IS DIVIDED INTO 4 PARTS
Part A- covers Hospital, skilled nursing facility, hospice, and home healthcare
Part B- covers medical care provided by physicians and other medical services
Part C- covers health care delivered by managed care plans
Part D- covers prescription drugs
MEDICARE PART A
ENROLLMENT
For people age 65 and covered by Social Security, enrollment in Medicare Part A is automatic on the first day of the month that they reach age 65 and is free. People not covered by Social Security may obtain Part A coverage under certain circumstances by paying a premium.
MEDICARE PART A
INPATIENT HOSPITAL COVERAGE
is for semi-private room and other usual charges for necessary hospital care; meals, supplies, medical services, drugs taken as an inpatient and so on.
It does not cover:
-Physician or surgeon charges
-private duty nurses
-the first 3 pints of blood
-charges for a phone, a tv, or other non medical services.
Part A inpatient hospital coverage is base on benefit periods rather than the calendar year. A benefit period begins when someone is admitted to the hospital and ends 60 days after discharge. If the person is readmitted within 60 days of discharge it does not start a new benefit period but is a continuation of the initial one.
For each benefit period, inpatient hospital coverage and cost sharing amounts are as follows:
- The patient pays a deductible, which changes annually
- days 1-60- fully paid by Medicare (after deductible)
- days 61-90- Medicare pays MOST of the cost, and the patient pays a daily co-pay amount which changes each year.
LIFETIME RESERVE DAYS
MEDICARE
For a stay in the hospital over 90 days, the patient may draw upon 60 lifetime days. The daily co-pay for lifetime reserve days is DOUBLE that of days 61-90. This co-pay amount also changes each year.
SKILLED NURSING FACILITY
MEDICARE
Is for people that need round-the-clock medical care provided by licensed nurses, but does not need the acute care provided by a hospital.
Medicare covers skilled nursing facility if:
-it is a Medicare-approved facility
-the SNF stay begins immediately after the release from a hospital stay of at least 3 days. If those conditions are met, Medicare coverage and cost sharing amounts for skilled nursing facility stay are as follows:
-day 1-20 fully paid by Medicare
-days 21 through 100 Medicare pays most of the cost and the patient pays a daily co-pay amount which changes each year.
After day 100, Medicare pays nothing.
HOME HEALTH CARE
MEDICARE
If a patient is confined at home Medicare Part A’s home health care benefit covers:
- visits by a home health aide to provide medical services such as part time nursing care and physical, occupational or speech therapy;
- 80% of the cost of durable medical equipment such as hospital beds or wheelchairs
The home healthcare benefit does not pay for:
- meals
- homemaker services such as shopping, cleaning, laundry.
HOSPICE
MEDICARE
Is for terminally ill patients and their families. It includes counseling, pain relief, and symptom management.
It may also include respite care, which is care provided temporarily in a hospice facility for a patient who is normally cared for in the home. The respite is for the usual caregivers.
MEDICARE PART A
EXCLUSIONS
Medicare Part A does NOT cover:
- first 3 pints of blood
- private duty nursing
- non-medical services
- intermediate care
- custodial care
MEDICARE PART B
ENROLLMENT
Individuals who enroll in Part A are automatically enrolled in Part B unless they request otherwise. Part B is optional and requires a monthly Part B premium. The Part B monthly premium is tied to an individual’s income level and is deducted from the Social Security monthly benefit check.
Part B enrollment occurs before the month an individual reaches age 65, coverage begins on the first day of that month (same as Part A coverage). If and individual initially declines Part B enrollment, they can enroll during the general enrollment period that occurs each year from January 1 through March 31 and coverage begins July 1.
MEDICARE PART B
COVERAGE
Medicare Part B provides coverage for 3 general kinds of medical services: inpatient and outpatient services, home health care (if not covered by Part A), and outpatient medical services and supplies. Also covered are physical, occupational, and speech therapy, medically necessary ambulance service, prosthetics, and drugs that cannot be self administered.
Some preventative care is included under Medicare Part B:
- an initial routine physical examination within the first 6 months of enrollment
- screening tests for cholesterol, diabetes, and colorectal
- annual mammograms (age 40 and over) pap tests, pelvic exams, and clinical breast exams for women
- annual prostate cancer screenings for men age 50 and over
- glaucoma testing once every 12 months
- bone mass measurements for qualified individuals
- flu shots
MEDICARE PART B COST SHARING
Medicare Part B has an annual deductible that changes each year and also a 20% coinsurance. Any part of the 3-pint deductible that has not been met under part A must be met under part B.
MEDICARE PART B
CLAIMS PROCESS
Medicare determines what the reasonable charge is for a particular service and the patient must pay the difference if the actual charge is more, unless the doctor or supplier agrees to accept assignment. –this means that the doctor or supplier will accept Medicare’s approved amounts as full payment and cannot legally bill the patient for anything above that amount—Doctors and suppliers are not required to accept assignment.
If Medicare decides that an expense is medically unnecessary, the patient must pay the entire cost.
If a doctor has not accepted a Medicare assignment, the bill is sent directly to the patient. they must fill out a Medicare claim form with the itemized bills including the date and place of treatment, description of treatment and the doctor’s name. The form and accompanying documents are sent to the Medicare carrier for the patient’s area. Upon receiving the claim, the carrier send the patient a form called Explanation of Medicare Benefits that itemizes the services covered and the approved payment for each service.
