Medicare Part B Darren Hotton Utah Aging and Adult Services
Eligibility <ul><li>Nearly everyone age 65 and over.   </li></ul><ul><li>Disabled individuals who have received 24 months ...
Those Who are Automatically Eligible   <ul><li>Those entitled to and receiving Social Security or Railroad Retirement cash...
Those Who are not Automatically Eligible   <ul><li>Those not entitled to Social Security or Railroad Retirement cash benef...
Enrollment Periods   <ul><li>Initial Enrollment   </li></ul><ul><ul><li>Seven‑month time period surrounding 65th birthday ...
Enrollment Periods   <ul><li>General Enrollment   </li></ul><ul><ul><li>First three months (January, February, March) of a...
Enrollment Periods <ul><li>Special Enrollment   </li></ul><ul><ul><li>At any time while the individual is covered by an em...
BENEFICIARY COSTS   <ul><li>Premium   </li></ul><ul><ul><li>The premium is $96.40 per month for 2008.   </li></ul></ul><ul...
How Much is the Part B Premium?
Medicare as Secondary Payer   <ul><li>Medicare is secondary payer to some group health plans (GHP's) for services provided...
Medicare as Secondary Payer cont. <ul><li>Situations in which another insurance may be primary to Medicare   </li></ul><ul...
BENEFITS   <ul><li>Covered Preventive Services </li></ul><ul><ul><li>Bone Mass Measurements   </li></ul></ul><ul><ul><li>C...
BENEFITS <ul><li>Covered Preventive Services </li></ul><ul><ul><li>Pap smears and pelvic examinations </li></ul></ul><ul><...
BENEFITS <ul><li>Major Covered Physician Services   </li></ul><ul><ul><li>Medical and surgical services (including anesthe...
Physicians’ Services Which May Be Covered   <ul><li>Clinical laboratory diagnostic services  (e.g.,  a blood test or a uri...
Non-Covered Physicians’ Services  <ul><li>Routine physical examinations and tests directly related to such examinations </...
Non-Covered Physicians’ Services cont. <ul><li>Immunizations   </li></ul><ul><li>Cosmetic surgery (unless it’s needed beca...
Coverage of Outpatient Hospital Services   <ul><li>Services in an emergency room or outpatient clinic.   </li></ul><ul><li...
Outpatient Physical Therapy and Speech Pathology Services <ul><li>Therapy services can be received in one of three ways : ...
Ambulance Transportation   <ul><li>Part B covers ambulance service if: </li></ul><ul><ul><li>the ambulance equipment and i...
Equipment and Supplies   <ul><li>Durable Medical Equipment:  Durable medical equipment includes products that can be used ...
Equipment and Supplies <ul><li>Parenteral and Enteral Nutrition Supplies:  Under this benefit, Medicare will cover intrave...
Medicare Publications <ul><li>Compare Care - Home Health Brochure - 11070   </li></ul><ul><li>Dialysis Facility Compare Br...
 
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Medicare Part B

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Medicare Part B

  1. 1. Medicare Part B Darren Hotton Utah Aging and Adult Services
  2. 2. Eligibility <ul><li>Nearly everyone age 65 and over. </li></ul><ul><li>Disabled individuals who have received 24 months of Social Security Disability benefits. </li></ul><ul><li>Persons with end‑stage renal (kidney) disease. </li></ul><ul><li>Determined by : </li></ul><ul><ul><li>Social Security Administration </li></ul></ul><ul><ul><li>Railroad Retirement Board </li></ul></ul>
  3. 3. Those Who are Automatically Eligible <ul><li>Those entitled to and receiving Social Security or Railroad Retirement cash benefits through early retirement are automatically entitled to Medicare Part B upon turning 65 unless they opt out of it. Also those Federal Retirees who retired after 1982 are eligible. </li></ul><ul><li>Those entitled to, but not receiving, Social Security or Railroad Retirement cash benefits upon turning 65 must apply for cash benefits or Part B of Medicare to receive them. </li></ul>
  4. 4. Those Who are not Automatically Eligible <ul><li>Those not entitled to Social Security or Railroad Retirement cash benefits must apply for Medicare Part B upon turning 65. They can apply for Part B without applying for Part A coverage. </li></ul>
  5. 5. Enrollment Periods <ul><li>Initial Enrollment </li></ul><ul><ul><li>Seven‑month time period surrounding 65th birthday (the three months prior to the month of the 65th birthday, the month of the 65th birthday, and the three months following the month of the 65th birthday). </li></ul></ul><ul><ul><li>The effective date for coverage during the initial enrollment period depends on the enrollment date </li></ul></ul><ul><ul><ul><li>If a person enrolls during the three months prior to the month the 65th birthday occurs, coverage begins on the first day of the month in which the person turns 65. </li></ul></ul></ul><ul><ul><ul><li>If a person enrolls during the month that the 65th birthday occurs, coverage begins on the first day of the month immediately following the birthday month </li></ul></ul></ul><ul><ul><ul><li>If a person enrolls during the three months following the month of the 65th birthday; coverage begins </li></ul></ul></ul><ul><ul><ul><ul><li>two months after enrolling when enrollment occurs in the first month following the birthday month, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>coverage begins three months after enrolling when enrollment occurs in the second or third month following the birthday month. </li></ul></ul></ul></ul>
  6. 6. Enrollment Periods <ul><li>General Enrollment </li></ul><ul><ul><li>First three months (January, February, March) of any year following the year of the 65th birthday. Coverage will be effective July 1st of that year. </li></ul></ul><ul><ul><li>Penalties For Late Enrollment: The Part B premium increases 10 percent for each 12-month period that enrollment (effective coverage) is delayed past the seven-month initial enrollment period. There is no cap on this penalty ( e.g. , a delay of five years will result in a penalty of 50 percent). </li></ul></ul>
  7. 7. Enrollment Periods <ul><li>Special Enrollment </li></ul><ul><ul><li>At any time while the individual is covered by an employer group health plan (EGHP) based on his or her own or a spouse’s current employment ( not retired); or, during the month of or any of the seven months following termination of the EGHP. </li></ul></ul><ul><ul><li>Coverage is effective the month of enrollment or any later month designated by the applicant. </li></ul></ul><ul><ul><li>There is no penalty for months the individual was eligible for Medicare but did not enroll because of EGHP based on current employment of himself/herself or spouse. </li></ul></ul>
  8. 8. BENEFICIARY COSTS <ul><li>Premium </li></ul><ul><ul><li>The premium is $96.40 per month for 2008. </li></ul></ul><ul><li>Deductible </li></ul><ul><ul><li>The beneficiary is required to meet a deductible of $135 once in any given year. </li></ul></ul><ul><li>Coinsurance Amount </li></ul><ul><ul><li>For most services, the coinsurance amount is 20 percent of the approved amount for 2008. </li></ul></ul><ul><li>Excess Charges </li></ul><ul><ul><li>In 2008, providers who do not accept Medicare assignment can charge no more than 115 percent of the approved amount for any service. </li></ul></ul>
  9. 9. How Much is the Part B Premium?
  10. 10. Medicare as Secondary Payer <ul><li>Medicare is secondary payer to some group health plans (GHP's) for services provided to the following groups of Medicare beneficiaries. GHP's cannot impose higher premiums or be more restrictive in benefits for Medicare beneficiaries than for all plan enrollees. </li></ul><ul><ul><li>The working aged: Employed people age 65 or over with employed spouses who have GHP coverage through an employer with more than 20 employees. </li></ul></ul><ul><ul><li>Younger people with permanent kidney failure: Medicare is secondary payer for 30 months for someone who has employer-sponsored insurance. </li></ul></ul><ul><ul><li>Certain disabled people: Medicare is secondary payer for Medicare-eligible disabled people who are also covered by a large group health plan (LGHP) by virtue of their own or a family member’s current employment status. The employer must employ 100 or more employees. </li></ul></ul>
  11. 11. Medicare as Secondary Payer cont. <ul><li>Situations in which another insurance may be primary to Medicare </li></ul><ul><ul><li>Auto accident or other no-fault insurance </li></ul></ul><ul><ul><li>Coverage by the Veterans Administration </li></ul></ul><ul><ul><li>Coverage by the Federal Black Lung program </li></ul></ul><ul><ul><li>Coverage through the Workers Compensation Fund </li></ul></ul><ul><ul><li>Liability insurance </li></ul></ul>
  12. 12. BENEFITS <ul><li>Covered Preventive Services </li></ul><ul><ul><li>Bone Mass Measurements </li></ul></ul><ul><ul><li>Cardiovascular Screening Blood Tests </li></ul></ul><ul><ul><li>Colorectal Cancer Screenings </li></ul></ul><ul><ul><li>Diabetes Monitoring Coverage </li></ul></ul><ul><ul><li>Diabetes Self-Management Training </li></ul></ul><ul><ul><li>Diabetes Medical Nutrition Therapy </li></ul></ul><ul><ul><li>Mammograms </li></ul></ul>
  13. 13. BENEFITS <ul><li>Covered Preventive Services </li></ul><ul><ul><li>Pap smears and pelvic examinations </li></ul></ul><ul><ul><li>Prostate Cancer Screening </li></ul></ul><ul><ul><li>Medical Nutrition Therapy </li></ul></ul><ul><ul><li>Glaucoma Testing </li></ul></ul><ul><ul><li>Vaccinations </li></ul></ul><ul><ul><li>Smoking Cessation </li></ul></ul><ul><ul><li>Welcome to Medicare Physical Exam </li></ul></ul><ul><ul><ul><li>One time only, within the first six months of enrolling in Medicare Part B. </li></ul></ul></ul>
  14. 14. BENEFITS <ul><li>Major Covered Physician Services </li></ul><ul><ul><li>Medical and surgical services (including anesthesia). </li></ul></ul><ul><ul><li>Diagnostic tests and procedures (including X‑rays). </li></ul></ul><ul><ul><li>Services of a doctor’s nurse (incident to the physician’s service). </li></ul></ul><ul><ul><li>Some drugs and biologicals administered by professionals. </li></ul></ul><ul><ul><li>Medical equipment and supplies other than common first‑aid needs. </li></ul></ul><ul><ul><li>Visit to a physician for second opinion about recommended surgery. </li></ul></ul><ul><ul><li>Dialysis maintenance services </li></ul></ul>
  15. 15. Physicians’ Services Which May Be Covered <ul><li>Clinical laboratory diagnostic services (e.g., a blood test or a urinalysis) </li></ul><ul><li>Outpatient treatment of mental illness </li></ul><ul><ul><li>Part B will pay for the treatment of a mental, psychoneurotic or personality disorder for an individual who is not an inpatient. Medicare Part B pays only 50 percent (rather than 80 percent) of approved amount. </li></ul></ul><ul><li>Chiropractors’ services </li></ul><ul><ul><li>Part B p ays for manual manipulation of the spine to correct a subluxation. </li></ul></ul><ul><li>Podiatrists’ services </li></ul><ul><ul><li>Covered services include: debridement of mycotic toenails, ingrown toenails, bunions, and heel spurs. </li></ul></ul>
  16. 16. Non-Covered Physicians’ Services <ul><li>Routine physical examinations and tests directly related to such examinations </li></ul><ul><li>Routine foot care including hygienic care, treatment for flat feet or other structural misalignments of the feet, and the removal of corns, warts (including plantar warts), and calluses except when related to medical conditions such as diabetes or peripheral vascular disease. </li></ul><ul><li>Hearing examinations specifically for prescribing or fitting hearing aids, and the cost of hearing aids. </li></ul><ul><li>Eye examinations specifically for prescribing or fitting eyeglasses, and the cost of eyeglasses (except one pair of eyeglass frames and one lens per eye, per lifetime, following cataract surgery). </li></ul>
  17. 17. Non-Covered Physicians’ Services cont. <ul><li>Immunizations </li></ul><ul><li>Cosmetic surgery (unless it’s needed because of an accidental injury, or to improve the functioning of a malformed part of the body). </li></ul><ul><li>Dental care (except for surgery of the jaw or related structures, or setting fractures of the jaw or facial bones). </li></ul><ul><li>Acupuncture. </li></ul><ul><li>Services connected with an experimental medical procedure. </li></ul><ul><li>Generally, self‑administered drugs are not covered by Part B. </li></ul>
  18. 18. Coverage of Outpatient Hospital Services <ul><li>Services in an emergency room or outpatient clinic. </li></ul><ul><li>Laboratory tests billed by the hospital (Medicare will pay 100 percent of approved amount even if the deductible is not met). </li></ul><ul><li>X‑rays and other radiology services billed by the hospital. </li></ul><ul><li>Medical supplies such as splints and casts. </li></ul><ul><li>Blood transfusions furnished to the beneficiary as an outpatient. </li></ul><ul><li>Services connected with treatment for alcoholism and drug dependency. </li></ul><ul><li>Maintenance dialysis. </li></ul>
  19. 19. Outpatient Physical Therapy and Speech Pathology Services <ul><li>Therapy services can be received in one of three ways : </li></ul><ul><ul><li>As part of treatment in a physician’s office </li></ul></ul><ul><ul><li>Directly from an independently practicing, Medicare‑certified physical therapist in the therapist’s office or in the home if such treatment is prescribed by a physician </li></ul></ul><ul><ul><li>As an outpatient of a participating hospital or skilled nursing facility (SNF), or from a home health agency (HHA), clinic, rehabilitation agency, or public health agency approved by Medicare </li></ul></ul><ul><ul><li>Beginning January 1, 2008, there is an annual combined limit of $1810 for outpatient physical therapy and speech language pathology. There is also an annual limit of $1810 for outpatient occupational therapy . </li></ul></ul>
  20. 20. Ambulance Transportation <ul><li>Part B covers ambulance service if: </li></ul><ul><ul><li>the ambulance equipment and its personnel meet Medicare requirements, and </li></ul></ul><ul><ul><li>transportation in any other vehicle would endanger the beneficiary’s health. </li></ul></ul><ul><li>Medicare covers ambulance service only to the closest facility capable of treating the patient. </li></ul><ul><li>Medicare covers ambulance service from the scene of an emergency or accident to a hospital, between a hospital and a SNF, or from a hospital or a SNF to the home. </li></ul>
  21. 21. Equipment and Supplies <ul><li>Durable Medical Equipment: Durable medical equipment includes products that can be used over and over again. Examples include wheelchairs, walkers, hospital beds, infusion pumps, canes, etc. </li></ul><ul><li>Oxygen: This benefit includes oxygen and oxygen equipment </li></ul><ul><li>Prosthetics and Orthotics: Devices such as artificial limbs, breast prosthesis, glasses (after cataract surgery), and braces may be covered. Ostomy and urological supplies are also included in this benefit </li></ul><ul><li>Medical Supplies: Many medical supplies used in the home may be billed to Medicare, including surgical dressings, blood glucose strips, etc. </li></ul>
  22. 22. Equipment and Supplies <ul><li>Parenteral and Enteral Nutrition Supplies: Under this benefit, Medicare will cover intravenous or tube feeding for patients with a permanent impairment that prevents him/her from eating normally. </li></ul><ul><li>Immunosuppressive Drugs: Immunosuppressive drugs may be covered for the benefit period after receiving a Medicare-approved organ transplant. </li></ul><ul><li>Home Dialysis Equipment and Supplies: Home dialysis supplies and equipment are covered when they are reasonable and necessary for a beneficiary with end stage renal disease (ESRD) who is being dialyzed at home under the supervision of a Medicare-approved dialysis facility. </li></ul><ul><li>Oral Anti-Cancer Drugs: This benefit includes anti-cancer medication that can be taken orally </li></ul>
  23. 23. Medicare Publications <ul><li>Compare Care - Home Health Brochure - 11070 </li></ul><ul><li>Dialysis Facility Compare Brochure - 10208 </li></ul><ul><li>Getting a Second Opinion Before Surgery - 02173 </li></ul><ul><li>How is the Part B Premium Changing? - 11218 </li></ul><ul><li>Medicare Basics: A Guide for Caregivers - 11034 </li></ul><ul><li>Preparing for Emergencies: A Guide for People on Dialysis - 10150 </li></ul><ul><li>You Can Live - Your Guide to Living with Kidney Failure - 02119 </li></ul><ul><li>Medicare & Clinical Trials - 02226 </li></ul><ul><li>Medicare and Your Mental Health Benefits - 10184 </li></ul><ul><li>Medicare Coverage of Ambulance Services - 11021 </li></ul><ul><li>Medicare Coverage of Durable Medical Equipment - 11045 </li></ul><ul><li>Medicare Coverage of Kidney Dialysis and Kidney Transplant Services - 10128 </li></ul><ul><li>New Billing for Certain Injectable and Infused Medicare Part B Drugs - 11148 </li></ul><ul><li>Protecting Medicare's Power Wheelchair and Scooter Benefits - 11046 </li></ul>
  24. 25. Questions

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