1 Copyright 2010 Delmar, Cengage Learning. All Rights Reserved.
© 2009 Cengage Learning. All Rights Reserved. Medicare.
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Transcript of © 2009 Cengage Learning. All Rights Reserved. Medicare.
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Medicare
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Agenda
Medicare coverage and eligibility Certification Payment Appeals
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Medicare Coverage and Eligibility
Part A Hospital Services Coverage
SNF, HHA, hospice Eligibility
Over age 65 and eligible for SSA Some disabled
Funding Payroll taxes
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Medicare Coverage and Eligibility
Part B Physician Services Coverage
Supplementary medical insurance
Eligibility Eligible for Part A and enrolled in Part B Medicare Advantage beneficiaries
Funding Premiums and co-payments
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Medicare Coverage and Eligibility
Part C Medicare Advantage Coverage
Parts A, B, and D May have supplemental benefits or discounts
Eligibility Eligible for Part A and enrolled in Part B
Funding Trust fund May have premiums or co-pays
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Medicare Coverage and Eligibility
Part D Prescription Drugs Coverage
Prescription drugs Eligibility
Eligible for Part A and enrolled in Part B Medicare Advantage beneficiaries (Part C)
Funding Supplementary Medical Insurance Trust Fund Premiums or co-payments
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Miscellaneous Medicare Provisions
Low Income Assistance Secondary payor rule Medigap National Coverage Decisions Advance Beneficiary Notice
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Certification
Conditions of Participation Providers Physicians and Suppliers Medicare Advantage Prescription Drug Providers
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Medicare Payment
Reimbursement Methodology Prospective Payment System (PPS) Diagnostic Related Groups (DRG) Special Adjustments
Low income patients Medical education programs Outliers
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Medicare Payment
Reimbursement for Physicians Resource Based Relative Value Scale
(RBRVS) HCFA Common Procedural Coding System
(HCPCS)
Capitation Market-Based System Assignment and Reassignment
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Medicare Appeals
Appeals by Providers, Physicians, and Other Suppliers for Parts A and B
Appeals by Beneficiaries for Parts C and D