Medicare Basics – The Four Parts of Medicare

April 18, 2018

Today’s Presenters

▪ Mimi Vier, CPC

▪ National Government Services, Inc.

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Disclaimer

National Government Services, Inc. has produced this material as an

informational reference for providers furnishing services in our contract

jurisdiction. National Government Services employees, agents, and staff

make no representation, warranty, or guarantee that this compilation of

Medicare information is error-free and will bear no responsibility or

liability for the results or consequences of the use of this material.

Although every reasonable effort has been made to assure the accuracy

of the information within these pages at the time of publication, the

Medicare Program is constantly changing, and it is the responsibility of

each provider to remain abreast of the Medicare Program requirements.

Any regulations, policies and/or guidelines cited in this publication are

subject to change without further notice. Current Medicare regulations

can be found on the CMS website at https://www.cms.gov.

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No Recording

▪ Attendees/providers are never permitted to

record (tape record or any other method) our

educational events

▪ This applies to our webinars, teleconferences, live events

and any other type of National Government Services

educational events

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Acronyms

▪ Please access the Acronyms page on the

NGSMedicare.com website to view any acronym

used within this presentation.

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Objectives

▪ This session will help connect the dots between

the traditional four parts of Medicare (Parts A, B,

C and D) and associated billing considerations

for providers and suppliers

▪ After this session, attendees will be more

familiar with all parts of the Medicare program

and will be able to distinguish differences

between traditional Medicare and Medicare

Advantage plan

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Agenda

▪ What Are the Four Parts of Medicare

▪ Part A – Hospital Insurance

▪ Part B – Medical Insurance

▪ Part C – Medicare Advantage Plans

▪ Part D – Drug Coverage

▪ Mandatory Medicare Claim Submission

▪ Medicare Tools for People with Medicare

▪ Wrap Up and Questions

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What are the Four Parts of Medicare?

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▪ Medicare was passed by Congress and signed by President Lyndon B. Johnson in 1965

▪ Medicare is a health insurance program for

▪ People 65 years of age and older

▪ Some people with disabilities

▪ People with end-stage renal disease (ESRD)

▪ Enrollment handled by Social Security Administration

▪ Administered by the Centers for Medicare & Medicaid Services (CMS) within the Department of Health & Human Services (DHHS)

Background

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▪ CMS is part of the U.S. Department of Health &

Human Services (HHS)

▪ Oversees Medicare, Medicaid, and SCHIP

▪ Establishes policies for paying health care providers

▪ Assesses quality of health care facilities and services

▪ Assures that Medicare is run properly by contractors

▪ Central office and regional offices

Centers for Medicare & Medicaid Services (CMS)

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What are the Four Parts of Medicare?

▪ Medicare Part A – hospital insurance

▪ Medicare Part B – medical insurance

▪ Outpatient services

▪ Physician services

▪ Durable medical equipment, prosthetics, orthotics and

suppliers (DMEPOS)

▪ Medicare Part C – Medicare Advantage plans

▪ Medicare Part D – prescription drug coverage

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▪ Private insurance companies

▪ Under contract with federal government

▪ Medicare Administrative Contractors

▪ Process both Part A and Part B claims

▪ DME

▪ Home Health and Hospice

▪ Federally Qualified Health Centers

▪ Contractors bound by service area

Medicare Contractors

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▪ Responsible for

▪ Medicare enrollment

▪ Premium billing and payment

▪ General Medicare questions (not claim-related)

▪ Replacement Medicare cards and questions regarding

enrollment

▪ Telephone Number: 1-800-772-1213

▪ Website: http://www.ssa.gov

Social Security Administration (SSA)

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Current Medicare Card

▪ Used for Medicare Parts A and B

Front

▪ More information on the back of the card

Back

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The New Medicare Number Project

▪ By April 2019, all Health Insurance Claim Numbers (HICN) will be replaced with a generic Medicare Beneficiary Identifier (MBI)

▪ Why is CMS doing this?

• To better protect private and federal health care benefits and the financial information tied to these health plans for an individual

▪ What is the difference?

• Currently a Medicare patient’s identification number is based on a SSN

• Each MBI is unique, randomly generated, and the characters are “non-intelligent,” which means they don’t have any hidden or special meaning

• The MBI is confidential and shall be protected as PII

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The New Medicare Number Project

▪ What do I do as a Medicare provider?

▪ Be aware and prepare

• Persons newly enrolled in Medicare as of 4/1/2018 will receive an MBI

• Existing Medicare patients will be transitioned to MBIs throughout 2018 and 2019 (January 2020 transition ends)

• Ensure your claims systems/vendors systems are updated to accept the entry and relay of the MBI to the MAC

• Encourage your Medicare patients to verify their address with SSA is correct

▪ Where do I find more information on this project?

▪ https://www.cms.gov/Medicare/New-Medicare-Card/index.html

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The New Medicare Card

▪ Example of the new Medicare Card

▪ https://www.cms.gov/Medicare/New-Medicare-Card/index.html

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Medicare Part A Helps to Pay

▪ Inpatient hospital stays

▪ SNF care

▪ Home health care

▪ Hospice care

▪ Blood

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Medicare Part B Helps to Pay for Medical Services

▪ Doctors’ services

▪ Outpatient medical/surgical services and supplies

▪ Diagnostic tests

▪ Outpatient therapy

▪ Mental health services

▪ Preventive services

▪ Clinical laboratory services

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Medicare Part B Helps to Pay for Medical Services

▪ DMEPOS

▪ Facility outpatient services (Part B of A) Including outpatient prospective payment system (OPPS) and FQHC

▪ Ambulance service

▪ Home health care

▪ Blood

▪ Medical nutrition therapy

▪ Other medical services

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Mandatory Medicare Claim Submission

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Billing Requirement

▪ The Social Security Act (Section 1848(g)(4)) requires▪ Claims must be submitted for all Medicare patients for services rendered on or

after 9/1/1990

▪ Applies to all physicians and suppliers who provide covered services to Medicare beneficiaries

• Requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment

▪ Medicare beneficiaries may not be charged for preparing or filing a Medicare claim

▪ Compliance with mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a ten percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare Program exclusion

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Claim Timely Filing Requirement

▪ Medicare regulations at 42 CFR 424.4425 define the timely filing period for Medicare fee-for-service claims ▪ In general, claims must be filed to the appropriate Medicare

claims processing contractor no later than 12 months, or one calendar year, after the date the services were furnished

▪ Determination that a claim was not filed timely is not subject to appeal

▪ Provider is responsible when a claim is not timely

• Must not charge beneficiary for such services except deductible and/or coinsurance

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Where Are Services Billed?

▪ Services are billed to Medicare Administrative Contractors (MAC)

▪ AB MAC

▪ Medicare Part A – hospital insurance

▪ Medicare Part B – medical insurance

▪ DME MAC

▪ Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

▪ Patient’s Medicare Advantage Plan

▪ Medicare Part C – Medicare Advantage plans

▪ Patient’s Prescription Drug Plan provider

▪ Medicare Part D – prescription drug coverage

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Locating Contractors (MACs and more)

▪ https://www.cms.gov/Research-

Statistics-Data-and-

Systems/Monitoring-

Programs/Medicare-FFS-

Compliance-Programs/Review-

Contractor-Directory-Interactive-

Map/#il

▪ Select the state and the

information populates below the

map

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Paperless Solutions

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Medicare Summary Notice

▪ Medicare Summary Notice (MSN) – mailed to people with Medicare once every 90 days – Part A and Part B for assigned claims

▪ MSN contains claims details such as date of service, procedure codes, payment information and resource information

▪ 1-800-MEDICARE or https://www.mymedicare.gov

▪ Electronic Medicare Summary Notice (eMSN)

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Paperless Solutions

▪ Provider Enrollment Chain & Ownership System (PECOS) is an Electronic Medicare enrollment system https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

▪ Submit: Enrollment; change of information; reactivation; revalidation; voluntary withdrawal/termination; reassign benefits

▪ View/print current enrollment information

▪ Track status of enrollment application

▪ Note: Once you update PECOS, allow 60 days for processing

▪ Additional information is available on our website; click on the Enrollment tab

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Paperless Solutions

▪ Electronic Remittance Advice (ERA)

▪ On our website > Enrollment > EDI Enrollment

▪ An EDI transaction allowing payment information to be received electronically

▪ With software, an ERA file created by Medicare can be automatically posted to your accounts receivable system thus allowing more efficient and accurate payment posting process

▪ Much quicker process than standard paper remittance (SPR) advice

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Understanding Medicare Part C:

Medicare Advantage Plans

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▪ Medicare Advantage (MA) plans are health plan options that are approved by Medicare and are run by private companies

▪ They are part of the Medicare Program and are sometimes called “Part C”

▪ Medicare Advantage Plan Directory

▪ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/MA-Plan-Directory.html

Medicare Part C: Medicare Advantage Plans

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▪ When a beneficiary selects a plan within an

MAO, all health care claims will have to be

submitted to that Medicare Advantage plan

Did You Know…

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How Do MA Plans Work?

▪ Beneficiaries get Medicare-covered services through the plan ▪ All Part A and Part B covered services

▪ Some plans may provide additional benefits

• Examples: Hearing aids, eyeglasses

▪ Most plans include prescription drug coverage ▪ Part D

▪ May have to go to network hospitals or doctors

▪ MA may be different than traditional fee-for-service Medicare ▪ Benefits and cost-sharing

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Frequently Asked Question

▪ Is an MA plan required to cover all of the

services that traditional Medicare covers or are

they allowed to exclude services?

▪ Answer: MA plans are required to cover all the services

that traditional Medicare covers; they are not allowed to

exclude such services

• MA plan may have different ways of covering the services

• MA plan may cover more services than traditional Medicare

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Medicare Advantage Claim Processing

▪ Reminder: Traditional (fee-for-service) Medicare

is NOT secondary to MA

▪ When an MA plan is in effect, bill all services for that

beneficiary to the MA plan

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Medicare Part D Drug Coverage

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Medicare Part D – Drug Coverage

▪ Available to all People with Medicare, voluntary; Medicaid automatic

▪ People must join a plan to get Medicare drug coverage

▪ Extra help paying drug plan costs is available to some people

▪ Medicare drug plans are offered by insurance companies and other private companies approved by Medicare

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Protect Your Bottom Line

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A Comprehensive Eligibility Verification Addresses These Questions

▪ Is patient entitled to Medicare coverage?

▪ Is patient’s identifying information reported accurately?

▪ Does patient have Part A, Part B?

▪ Enrolled in an MA plan?

▪ Is patient enrolled in hospice?

▪ Does patient have insurance primary to Medicare (MSP

situation)?

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▪ Maintains national beneficiary records

▪ Entitlement, date of birth, and date of death

▪ Recent benefit periods (including any deductibles due)

▪ MA enrollment

▪ Home health episode

▪ Preventive services

▪ Hospice enrollment

▪ MSP information

What is CWF?

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Termination of Provider CWF Access

▪ CR 8248 – HIQA, HIQH, HUQA, ELGA, ELGH

will be terminated

▪ CMS released SE1249 on 2/12/2014:

▪ “While termination was originally scheduled for April 2014,

CMS is delaying the date. CMS will provide at least 90

days advanced notice of the new termination date.”

▪ Providers advised to use HETS system as

replacement for CWF access

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What is HETS?

▪ HIPAA Eligibility Transaction System

▪ Provides same eligibility data as HIQA, with some exceptions

▪ http://www.cms.gov

• Research, Statistics, Data and Systems > HIPAA Eligibility Transaction System (HETS) Help (270/271)

▪ CMS website has section on HETS, including:

• Vendor and registration information

• HETS user guide

• FAQs

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▪ Patient presents insurance information and/or cards

▪ Provider determines proper order of insurance

▪ Must know COB/MSP concepts

▪ Provider verifies Medicare eligibility

▪ Patient

▪ CWF/FISS

▪ IVR

▪ NGSConnex (NGS providers only)

Proper Claim Submission Starts at Patient Registration

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▪ Conduct MSP screening process

▪ Registrar discusses questions with beneficiary

▪ Keep copy of answers either hardcopy or electronically

▪ Provider must compare information gathered

with Medicare system information prior to

submitting claims

MSP Screening Process

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▪ Compare MSP information in Medicare’s records to collected MSP information

▪ Determine proper primary payer

▪ MSP Provision conditions/criteria met?

▪ Resolve conflicts

▪ May need to have Medicare’s records updated by Benefits Coordination & Recovery Center (BCRC)

▪ Submit claims accordingly

Determining the Proper Primary Payer

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▪ Report employment changes, any other insurance coverage information

▪ Report liability, automobile/no-fault, and workers compensation case

▪ Add new MSP file to CWF

▪ General MSP questions/concerns

▪ Telephone inquiries to BCRC: 1-855-798-2627

• CMS MLN SE1416 “Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)”

Benefits Coordination & Recovery Center (BCRC)

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Medicare Tools for People with

Medicare

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▪ State Health Insurance Assistance Program

▪ https://www.shiptacenter.org/ or contact your

▪ Home page > Need Local Help with Medicare? Contact

your state SHIP > use drop-down box to select your state

Medicare Tools for People with Medicare

Medicare Tools for People with Medicare

▪ “Medicare & You” Handbook

▪ https://www.Medicare.gov > Forms, Help, &

Resources > select the handbook from the drop-

down box

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References, Resources & Wrap-up

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Resources

▪ CMS Manuals

▪ http://www.cms.gov/Manuals/IOM/list.asp

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual,

Chapter 13

• CMS IOM Publication 100-04, Medicare Claims Processing Manual,

Chapter 9

• Medicare Advantage Resource

– CMS IOM Publication 100-16, Medicare Managed Care Manual

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Resources

▪ FQHC Center

▪ https://www.cms.gov/Center/Provider-Type/Federally-

Qualified-Health-Centers-FQHC-Center.html

• FQHC GAFs effective 01/01/2018-12/31/2018

• FQHC PPS Specific Payment Codes (Qualifying Visit codes)

• FQHC PPS FAQs

• FQHC Preventive Services Guide

• FQHC Fact Sheet

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Resources

▪ National Uniform Billing Committee

• http://www.nubc.org/

• NUBC Official UB-04 Data Specifications Manual

• Annual fee

• Providers also receive updates throughout the year

▪ U.S. Preventive Services Task Force (USPSTF)

• http://www.uspreventiveservicestaskforce.org

– Provides Grade A and B preventive services

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Preventive Services Resources

▪ Preventive Services – provider resources ▪ https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Pro

viderResources.html

▪ Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B▪ https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNProducts/Downloads/qr_immun_bill.pdf

▪ Preventive Services Interactive Chart ▪ https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/me

dicare-preventive-services/MPS-QuickReferenceChart-1.html

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▪ Medicare Advantage Plan Directory

▪ https://www.cms.gov/MCRAdvPartDEnrolData/PDMCPDO/list.asp

▪ Quick Reference New Medicare Provider

▪ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Quick_Reference_New_Provider.pdf

▪ Medicare Enrollment and Claim Submission Guidelines

▪ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

CMS Resources

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▪ Two Ways to Contact Us:

▪ Telephone Inquiries

▪ Written Inquiries

▪ Contact Information

▪ http://www.NGSMedicare.com > Contact Us

Provider Inquiries to NGS

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▪ http://www.NGSMedicare.com

▪ Medicare Monthly Review

• Published monthly

• Updates and changes to Medicare

• New and revised LCDs

• Upcoming educational sessions

▪ Electronic mailing list (E-mail Update)

• New Medicare information (billing and coverage)

• Provider education and training announcements

Information for NGS Providers

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Thank You!

▪ Questions?

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