CMS: World of Medicare

Medicare Program

a federal health insurance program for those:

65 and older

under 65 with certain disabilities

with end-stage renal disease (ESRD)

How is the Medicare Program paid for?

workers and employers payroll taxes

premiums people with Medicare pay

Detail the history of Medicare

1960s: President Johnson signs Medicare & Medicaid programs into law

1970s: Medicare Program expanded by Congress to include certain disabled people with ESRD; Department of Health, Education, and Welfare creates the Health Care Financing Administration to coordinate the Medicare and Medicaid Programs

1980s: Department of Health, Education, and Welfare divided into the Department of Education and Department of Health and Human Services

1990s: Medicare offers Part C health care options

2000s: Medicare and Medicaid and State Children’s Health Insurance Program (CHIP) approved by Congress; HCFA renamed the Centers for Medicare and Medicaid Services (CMS); Medicare drug plan legislated in the MMA starts

2010s: ACA includes reforms that generate savings and offer new benefits and services to help keep people with Medicare healthy

2020s: ESRD Treatment Choices Model created & updated

Title XVIII of the Social Security Act

established Medicare to provide health insurance for people ages 65 and older

program included Medicare Part A and Part B (a.k.a Original Medicare)

Title XIX of the Social Security Act

established Medicaid to pay for medical assistance for certain people and families with low incomes and limited resources

Social Security Administration (SSA)

originally oversees the Medicare Program

enrolls most people in Medicare

Social and Rehabilitation Service (SRS)

works with the federally funded state Medicaid Program

Benefits Improvement and Protection Act

waives the 24 month waiting period before Medicare entitlement for people with ALS who are eligible for Social Security disability benefits

improves preventive benefits and benefits for some drugs

Medicare Prescription Drug Improvement and Modernization Act (MMA)

makes Medicare a more prevention-focused program

allows Medicare Advantage plans

Medicare Improvements for Patients and Providers Act of 2008

improves coverage of mental health, supplemental and preventive health services

creates new rules for Medicare Advantage marketing

Section 3021 of the ACA

creates the ESRD Treatment Choices (ETC) Model which gives ESRD patients the freedom to choose ESRD treatment that best works with their lifestyle

Health Equity Incentive under the ESRD Prospective Payment System (PPS)

encourages dialysis facilities and health care providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients

List the 4 parts of Medicare

Medicare Part A

Medicare Part B

Medicare Part C

Medicare Part D

Medicare Part A

also known as hospital insurance

helps pay for:

inpatient hospital care

inpatient care in a skilled nursing facility (SNF) after a covered hospital stay

some health care

home health services

hospice care

Medicare Part B

a voluntary program that includes a monthly premium; may face penalties if enrolled in later

helps pay for medical services including:

physician services (e.g. surgery, consultation, office & institutional calls, services, and supplies offered incident to a physician’s professional service)

some preventive services

home health for people without Part A

ambulance services

laboratory and diagnostic services (e.g. laboratory test, x-ray & diagnostic test)

surgical supplies

durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

hospital outpatient services (e.g. diagnostic services, physical/occupational/speech-language pathology therapy)

Rural Health Clinic (RHC) services

Federally Qualified Health Center (FQHC) services

certain prescription drugs

Opioid Treatment Programs (OTPs)

*doesn’t cover inpatient hospital facility services

Medicare Part C

refers to Medicare Advantage plans that Medicare-approved private insurance companies offer; Medicare sets rules companies must follow

MA plans must cover all services that Part A and Part B cover except hospice care

Ma plans also can offer other benefits that traditional Medicare doesn’t pay for

allows people with Medicare to enroll in MA Plans instead of getting Medicare benefits through Original Medicare

Medicare Part D

the Medicare drug plan

offers prescription drug coverage to all people with Medicare who choose to enroll

insurance plans or private companies contract with Medicare to provide these services

plans vary in cost and what drugs they cover

anyone who has Part A or Part B and lives in a plan’s service area is eligible to join the plan

Original Medicare

offers coverage for Medicare Part A or Part B as a fee-for-service benefit

Medigap policy

only works with Original Medicare; monthly premium must be paid

an option people can buy to help pay for some of the health care costs that Original Medicare doesn’t cover; helps people pay for their out-of-pocket costs, as well as other services Medicare doesn’t cover

must have Medicare Parts A and B to buy a Medigap policy

enrollees of Original Medicare with a Medigap policy have Medicare and Medigap each paying their share of covered health care costs

standardized by federal law; each plan has a different set of benefits, only difference is cost

List Medicare choices

Original Medicare

Medigap

Medicare drug plan/Part D

Medicare Advantage (MA)/Part C

Medicare Advantage (MA) Plan

also called Medicare Part C; offers Part A and Part B benefits except hospice

many MA plans include Medicare prescription drug coverage

Medigap policy not needed because MA plans generally cover many of the same benefits that Medigap covers

List Medicare choice options for patients:

step 1: choose either Original Medicare or MA Plan

step 2: decide if supplemental coverage is needed

step 3: decided if prescription drug coverage is needed

For services covered by both Medicare and Medicaid, which pays first?

Medicare and then Medicaid up to the state’s payment limit

How do people enroll in the Medicare Program?

through an automatic enrollment process or by applying to the program when they are eligible

Railroad Retirement Board (RRB)

enrolls railroad retirees in Medicare

Part A eligibility

certain income requirements based on own earnings or those of a spouse, parent, or child

worker must have a specific number of quarters of coverage (QCs)

“Entitled To” Section

lets healthcare professionals know if a person has Original Medicare benefits

Medicare Beneficiary Identifier (MBI)

a unique randomly assigned number for CMS Medicare cards

Part B eligibility

people entitled to premium-free Part A are eligible for Part B

Medicare Part B premiums taken out of monthly checks for people with Medicare by the SSA, RRB, and Office of Personnel Management (OPM)

Part B enrollment periods

initial enrollment period (IEP)

general enrollment period (GEP)

special enrollment period (SEP)

MA and Part D also have enrollments periods like Part B

initial enrollment period (IEP)

lasts for 7 months starting 3 months before eligibility (age 65, the 25th month of disability benefit entitlement, or Part A entitlement date for people with ESRD)

general enrollment period (GEP)

for people who refused Part B during the IEP or whose Part B coverage was ended 1/1-3/31 of each year or coverage effective 7/1

special enrollment period (SEP)

people who delayed enrolling in Part B because they or their spouse had group health coverage based on employment can sign up for Part B with no increased premium any time if they have group health plan coverage based on current employment or within 8 months of the end of the employer or union health plan coverage

People disenrolling from an MA Plan except a Medicare Savings Account (MSA) Plan

may return to Original Medicare during the open enrollment period for Medicare Advantage and Medicare prescription drug coverage (10/15-12/7) or Medicare Advantage open enrollment period 1/1-3/31

provider

refers to any person or entity enrolled in Medicare who offers health care or services

Detail provider choices when enrolling in the Medicare Program

step 1: apply to enroll in Original Medicare

step 2: decide whether to apply to enroll in any MA plans

retail pharmacies

can enroll in Medicare to offer covered Part B services as a supplier

decide whether to contract with specific MA Plans or the Medicare drug plan

List conditions for being deemed contracting for providers of services to a Medicare Advantage (MA) Plan private-fee-for-service plan enrollee

know before supplying services that the person getting services is enrolled in a PFFS Plan

have access to the plans’s terms and conditions of payment

plan covers the service offered

private-fee-for-service (PFFS) plan

a type of MA plan in which people may go to any Medicare-approved provider if the provider agrees to accept the plan’s terms of payment before treating the patient

may have extra benefits

insurance plan instead of the Medicare Program decides how much it will pay and what a person will pay for services

The Centers for Medicare & Medicaid Services (CMS)

an agency of the U.S. Department of Health & Human Services (HHS) that oversees the Medicare Program

goal is to provide effective health care coverage and promote quality care for people with Medicare

List functions of CMS

makes sure its contractors and state agencies properly administer Medicare

issues policy for provider payment

identifies and tests ways to improve health care management and treatment

assesses the quality of health care facilities and services

works with states to oversee the Medicaid Program, the Health Insurance Marketplace, and CHIP

Medicare Contractors

work with CMS to process Medicare claims

include:

Medicare Administrative Contractors (MACs)

MA Plan contractors

Medicare drug plan contractors

organizations

work with CMS to run the Medicare Program

help oversee program integrity, quality improvement, and patient support

some mostly work with Medicare providers and others work with people enrolled in Medicare

List examples of Medicare organizations

Benefits Coordination & Recovery Center (BCRC)

Comprehensive Error Rate Testing (CERT) Contractor

Office of Inspector General (OIG)

Qualified Independent Contractor (QIC)

Quality Improvement Organization (QIO)

Railroad Retirement Board (RRB)

Recovery Audit Contractors (RACs)

Social Security Administration (SSA)

State Survey Agency (SA)

Unified Program Integrity Contractors (UPICs)

Benefits Coordination & Recovery Center (BCRC)

doesn’t process claims

allows plans that offer health or prescription coverage for a person with Medicare to determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when a person is covered by more than 1 plan

consolidates the activities that support the collection, management, and reporting of other insurance coverage for people with Medicare

helps a person identify health benefits and coordinates the payment process to prevent mistaken payment of Medicare benefits

Comprehensive Error Rate Testing (CERT) Contractor

measures and improves the quality and accuracy of Medicare claims submission, processing, and payment

CERT contractor calculates the Medicare FFS error rate and estimates of improper claim payments by reviewing a random sample of submitted claims and medical records

Office of Inspector General (OIG)

protects the integrity of HHS programs and the health and welfare of the people in those programs through a nationwide network of audits, investigations, inspections, and other related functions

Qualified Independent Contractor (QIC)

responsible for conducting the second level of appeals (reconsiderations of initial determinations and redeterminations of Medicare claims)

Medicare Administrative Contractors (MACs)

an organization that contracts with CMS to oversee the Medicare Program within a specified jurisdiction

are multistate, regional contractors responsible for administering both Part A and Part B claims

responsible for handling the first level of appeals

Quality Improvement Organization (QIO)

a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare

List the 2 types of QIOs that work under CMS’s direction in support of the QIO Program

Beneficiary and Family Centered Care (BFCC)-QIO

Quality Innovation Network (QIN)-QIOs

Recovery Audit Contractors (RACs)

review claims on a post-payment basis

detect and correct past improper payments

State Survey Agency (SA)

perform initial surveys (inspections) and periodic resurveys (including complaint surveys) of all providers and certain kinds of suppliers

Unified Program Integrity Contractors (UPICs)

perform fraud, waste, and abuse detection, deterrence, and prevention activities for Medicare and Medicaid claims processed in the U.S

perform integrity-related activities associated with Medicare Parts A, B, DME, Home Health and Hospice (HHH), Medicaid, and the Medicare-Medicaid Data match program (Medi-Medi)

Medicare

refers to people who qualify for both Medicare and Medicaid as dually eligible beneficiaries

What do you have to do to become a Medicare provider and get payment from Medicare?

complete an enrollment application

CMS collects your information and makes sure you’re qualified and eligible to enroll in the Medicare Program

List examples of providers who send claims for Part A benefits

hospitals

skilled nursing facilities (SNFs)

home health agencies (HHAs)

critical access hospitals (CAHs)

hospice agencies

List examples of suppliers who send claims for Part benefits

physicians

non-physician practitioners

other suppliers (e.g. ambulance, DMEPOS, and clinical labs)

hospitals, SNFs, HHAs, and CAHs can also send claims

What does payment for Original Medicare services depend on?

services meeting benefit categories

services not being specifically excluded from coverage

items or services being reasonable and necessary

List items & services generally not covered by Medicare Part A & Part B

acupuncture

chiropractic services, except to correct a subluxation using manipulation of the spine

cosmetic surgery

custodial care

dental care and dentures

eye care (routine exam), eye refractions, and most eyeglasses

foot care

health care while traveling outside the U.S.

hearing aids and exams for the purpose of fitting a hearing aid

hearing tests not ordered by a doctor

long-term care services and supports (long-stay nursing home and home and community-based services)

orthopedic shoes (with few exceptions)

prescription drugs (Medicare doesn’t cover most outpatient drugs)

syringes or insulin, unless the insulin is used with an insulin pump

What must people with Medicare pay?

deductible and coinsurance for most services

deductible

amount a person must pay before Medicare starts to pay for services and supplies covered under the program

coinsurance

the share of the cost for services a person must pay after they meet the deductible

Medigap enrollment

starts of the first day of the month in which an individual is both 65 and enrolled in Medicare Part B

open enrollment period lasts 6 months (insurance companies can’t deny people with Medicare coverage due to past or present health problems during this period)

Medigap insurance companies may use health history to decide eligibility for Medigap policy and how much must be paid for the policy after the end of a person’s open enrollment period

guaranteed issue rights

insurance companies must offer certain Medigap policies even if the person has health problems

medical underwriting

the process insurance companies use to decide whether to take an individual’s application for insurance, whether to add a waiting period for pre-existing conditions (if state law allows it), and how much to charge the individual for that insurance

decision based on an individual’s medical history

*people must go through in order to get Medigap policy back after dropping

Medigap policies sold before 2006

included outpatient prescription drug benefits

those who still have this coverage and choose not to sign up for a Medicare drug plan may keep this policy that includes outpatient drug coverage

List MACs that work with Original Medicare

Part A/B Medicare Administrative Contractors (A/B MACs)

durable medical equipment medicare administrative contractors (DME MACs)

home health and hospice medicare administrative contractors (HHH MACs)

List MAC responsibilities

primary contact between you and the Medicare FFS program

processing Medicare FFS claims

making and accounting for Medicare FFS payments

enrolling providers

handling reimbursement services and auditing institutional provider cost reports

handling redetermination requests (first-stage appeals process)

answering questions

teaching about Medicare FFS billing needs

setting up local coverage determinations (LCDs)

reviewing medical records for selected claims

coordinating with CMS and other FFS contractors

participating supplier

voluntarily signs an agreement with Medicare to accept assignment for all services given to people with Medicare

means the supplier accepts Medicare's allowed amounts as payment in full for services and doesn’t collect more than the Medicare deductible and coinsurance or copayment from the patient

non-participating supplier

doesn’t sign an agreement

can still accept assignment of Medicare claims on a case-by-case basis

List conditions for joining an MA Plan

be entitled to Part A and enrolled in Part B

permanently live in the service area of the MA plan

choose to enroll in an MA Plan

people of any age with ESRD can enroll in MA plans starting 1/1/21

Detail how MA Plans works

MA Plans offer Part A and Part B coverage except hospice (Original Medicare pays for Medicare-covered services that an MA plan patient gets while in hospice care)

offers extra benefits such as vision, hearing, dental, and health and wellness programs, and may include drug coverage

generally have provider networks

people who switch from Original Medicare to an MA Plan and also have a Medigap policy can’t use the Medigap policy to cover deductibles, copayments, or coinsurance while enrolled in the MA Plan

some MA Plans charge enrollees a monthly premium which is added on to the Part B premium people pay to Medicare, though some plans pay all or part of the Part B premium; costs vary

plan may have a yearly deductible or additional deductible for some health services as well as payment for each doctor’s visit or service

dually eligible people (those who qualify for Medicare and Medicaid) may get help with their MA Plan costs from the Medicaid Program, depending on their level of Medicaid coverage

List types of MA Plans

PFFS

HMO

MSA

PPO

SNP

Health Maintenance Organization (HMO)

generally allows enrollees to only go to doctors, specialists, or hospitals that are part of the plan’s network, except in an emergency

Medical Savings Account

combine a high deductible health plan with a Medical Savings Account that people can use to manage their health care costs

covers 100% of Part A and Part B costs once deductible is met

don’t have premiums

don’t cover prescription drugs, but we allow people to enroll in a drug plan

Preferred Provider Organization (PPO)

have network providers, but people can also use out-of-network providers for services their plan covers, usually for a higher cost

Special Needs Plan (SNP)

offers benefits and services to people with specific diseases, certain health care needs, or limited incomes

tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve

membership is limited to certain groups of people, including those in institutions such as nursing homes, those eligible for both Medicare and Medicaid, or those with some chronic or disabling conditions

MA Plan Contractors

must contract with CMS (each contract is for a calendar year)

must meet enrollment requirements and follow MA Plan marketing guidelines

MA contracts automatically renew from term-to-term unless CMS or the MA organization gives notice of the intent to non-renew or end the contract at the end of the current term

MA provider selection

MA service providers must have an agreement with CMS allowing them to offer services under Original Medicare

certain health care professionals must undergo credentialing to join a provider network

MA organizations must provide a written notice of the reason for their decision to decline inclusion in its network

MACs can’t process MA plan claims

MA Plan benefits

may change from year to year; plans send an Annual Notice of Change (ANOC) to enrollees each fall that has information about changes in premium, benefits, cost sharing, or service area effective in January of the following year

send enrollees an Evidence of Coverage (EOC) each year that gives details such as what benefits the plan will cover, how much the person will pay, and how to file an appeal

Detail how to get drug coverage

joining a Medicare drug plan or selecting a Medicare Advantage Plan that includes drug coverage

*for people with Medicare who don’t have prescription drug coverage through an employer or union, TRICARE for Life, COBRA, or other means

Medicare drug plan sponsors

nongovernmental entities under contract with CMS to offer prescription drug benefits

each plan must give enrollees the information they need to decide their prescription drug coverage each year, including the plan’s service area, benefits, and covered drugs

Drug plan benefits vary depending on:

what drugs the plan covers

how much the person pays

which pharmacies a person can use

*coverage and cost differ but all Medicare drug plans must offer at least a standard level of coverage that Medicare sets

Drugs covered under the Medicare drug plan must be:

available only by prescription

FDA approved

used and sold in the U.S.

*drug plans don’t cover drugs excluded by law, non-prescription drugs, and drugs covered under Part B

*OTC drugs generally not covered but Part D covers medical supplies associated with the injection of insulin and not covered under Part B. This includes insulin syringes, needles, alcohol swabs, and gauze

List covered conditions for Medicare drug plans

cancer medications

HIV/AIDS treatments

antidepressants

antipsychotic medications

anticonvulsive treatments for epilepsy seizure disorders and other conditions

immunosuppressants

formulary

a list of drugs the plan covers; must meet Medicare’s rules

may not include every Medicare-covered drug but usually cover a like drug that is safe and effective

can change during the year because of drug therapy changes, new drugs, or new medical information; must tell enrollees at least 60 days in advance of formulary changes that affect a drug they take

*use Medicare Plan Finder>Find Plans Now under Find health & drug plans to find out which plans cover specific prescription drugs

tiers

cost-sharing levels

What happens to Ma enrollees with drug coverage who join a Medicare drug plan?

they are disenrolled from their MA Plans and returned to Original Medicare (people disenrolled during the MA Disenrollment Period 1/1-2/14 each year may may choose a new drug plan regardless of whether they had earlier Medicare drug coverage)

different rules apply to a Medical Savings Account (MSA) Plan or an MA Private Fee-for-Service (PFFS) Plan without drug coverage

Late Enrollment

those who don’t enroll in a drug plan when first eligible may pay a penalty to enroll in a plan later if they don’t keep creditable coverage

those who wait until after their Part D IEP ends to join a plan will see their premiums go up 1% for every month they waited to enroll, penalty must be paid as long as they have Medicare drug coverage

creditable coverage

drug coverage from an employer or a union that’s expected to pay, on average, at least as much as Medicare’s standard drug coverage

those who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare drug coverage later

List what people are responsible for paying in a Medicare drug plan

monthly premiums

annual deductible

copayments or coinsurance

a small copayment for the rest of the calendar year after they reach a certain out-of-pocket amount

coverage gap

after people reach a drug plan’s standard level of coverage, they may have to pay costs for their prescriptions until reaching a catastrophic coverage level

people who reach the coverage gap get a discount when buying Part D-covered brand-name or generic prescription drugs

catastrophic coverage

offered for people that have an unexpected illness or injury resulting in extremely high drug costs

pays almost all drug costs after the patient has paid a set amount of drug costs out-of-pocket during a calendar year

Extra Help Program

helps people with limited income and resources pay their Medicare prescription drug coverage costs

helps those who qualify not be penalized for late-enrollment or helps them pay the penalty

automatically enrolls people who qualify for the program but don’t choose a drug plan

*people with the lowest incomes pay no premiums or deductibles and have small or no copayments

*people with slightly higher incomes have no premium or a reduced premium and a reduced deductible, they also pay a little more out of pocket

List the 6 steps to becoming a Medicare provider

register in the I&A System

get an NPI

enter information into PECOS

decide if you want to be a participating provider

check status of pending enrollment application

keep enrollment information up to date

Identity & Access (I&A) Management System

lets you create 1 user account to manage access to CMS systems such as PECOS

National Provider Identifier (NPI)

mandated standard unique identifiers by HIPAA for health care providers and health plans for electronic transmission of health information

NPIs are:

10-digit numeric identifiers that don’t change

used in HIPAA standard transactions

needed to enroll as a Medicare provider or supplier

National Plan & Provider Enumeration System (NPPES)

developed by CMS to assign NPIs

Provider Enrollment, Chain & Ownership System (PECOS)

the preferred method for provider enrollment

an electronic Medicare enrollment system through which providers and suppliers can:

send Medicare enrollment applications

view and print enrollment information

update enrollment information

omplete the revalidation process

voluntarily withdraw from the Medicare Program

track the status of a sent Medicare enrollment application

a scenario-driven, interactive application process with built-in help screens

makes sure that physicians and non-physician practitioners complete and send only the information necessary to enroll or make a change in their Medicare enrollment record