Medicare

Agenda

Medicare coverage and eligibility Certification Payment Appeals

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

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

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

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

Miscellaneous Medicare Provisions

Low Income Assistance Secondary payor rule Medigap National Coverage Decisions Advance Beneficiary Notice

Certification

Conditions of Participation Providers Physicians and Suppliers Medicare Advantage Prescription Drug Providers

Medicare Payment

Reimbursement Methodology Prospective Payment System (PPS) Diagnostic Related Groups (DRG) Special Adjustments

Low income patients Medical education programs Outliers

Medicare Payment

Reimbursement for Physicians Resource Based Relative Value Scale

(RBRVS) HCFA Common Procedural Coding System

(HCPCS)

Capitation Market-Based System Assignment and Reassignment

Medicare Appeals

Appeals by Providers, Physicians, and Other Suppliers for Parts A and B

Appeals by Beneficiaries for Parts C and D