9780872186835

All About Medicare, 2006

by
  • ISBN13:

    9780872186835

  • ISBN10:

    0872186830

  • Format: Paperback
  • Copyright: 2006-03-15
  • Publisher: Natl Underwriter Co
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Table of Contents

INTRODUCTION 1(12)
Medicare Defined
Administration of Medicare
Hospital Insurance Protection
Medical Insurance Protection
Providers of Services and Supplies
Hospital Insurance
Medical Insurance
Home Health Coverage
Limit on Benefits
Availability of Benefits
Medicare Card
Care Not Covered by Medicare
Quality Improvement Organizations
Fraud and Abuse Hotline
Fee-for-Service System Versus Medicare Advantage
PART A: HOSPITAL INSURANCE 13(32)
ELIGIBILITY
13(9)
Who Is Eligible
End-Stage Renal Disease
Government Employees
Medicare as Secondary Payer
Persons Who Do Not Qualify for Social Security
Special Enrollment Premium
ADMINISTRATION
22(1)
Centers for Medicare & Medicaid Services
Prospective Payment System
Compulsory Nature of Plan
FINANCING HOSPITAL INSURANCE (PART A)
23(1)
Hospital Insurance Tax
BENEFITS
24(1)
Generally
QUALIFIED MEDICARE BENEFICIARIES
24(2)
Medicare Costs Paid by State
How to Qualify
Income Above Poverty Level
Applying for Assistance
INPATIENT HOSPITAL SERVICES
26(5)
Services Covered
Care in Psychiatric Hospital
Religious Nonmedical Health Care Institutions
Selecting a Hospital
Certification by Doctor
Hospital Agreement with Medicare
HOSPICE CARE
31(3)
Hospice Care Defined
How Hospice Care is Covered
Hospice Benefit Period
Cost to Patient
Respite Care
SKILLED NURSING FACILITY CARE
34(4)
Definition
Services Covered
Cost to Patient
When Payment is Made
HOME HEALTH CARE
38(5)
When Services Are Covered
Conditions for Coverage
Services Covered by Medicare
How Medicare Pays the Cost
GENERAL INFORMATION
43(2)
Outpatient Hospital Services
Financial Need
Increases in Deductible and Coinsurance Amounts
Living Will and Durable Power of Attorney
PART B: MEDICAL INSURANCE 45(26)
ELIGIBILITY
45(3)
Who Is Eligible
How to Enroll
Failure to Enroll During Automatic Enrollment Period
Federal-State Agreement
Special Enrollment Period for Certain Disabled Workers
Terminating Coverage
FINANCING MEDICAL INSURANCE
48(7)
How Program is Financed
Qualified Medicare Beneficiary
How Premiums are Paid
Determining "Approved Charges"
How Payments are Made
Medicare-Participating Doctors
Medicare Supplier
Cost Paid By Patient
How Patient Finds Out How Much Medicare Will Pay
BENEFITS
55(13)
Doctors' Services
Outpatient Hospital Services
Outpatient Physical Therapy and Speech Pathology Services
Partial Hospitalization Services
Certified Nurse-Midwife Services
Dental Work
Medical Equipment
Ambulance Service
Outpatient Treatment of Mental Illness
Vaccines
Antigens
Liver Transplant
Comprehensive Outpatient Rehabilitation Facility
Home Health Services
Independent Clinical Laboratory Services
Screening Pap Smears
Breast Cancer Screening
Prostate Screening
Colorectal Screening
Diabetes Benefits
Bone Mass Measurements
Osteoporosis
Eyeglasses
Nurse Practitioners
Lung and Heart-Lung Transplants
Immunosuppressive Drugs
Ambulatory Surgical Services
Rural Health Clinic Services
Telehealth Services
Federally Qualified Health Center Services
Other Benefits
Services Covered With No Cost Sharing
MEDICARE COVERAGE OF BLOOD
68(1)
How Medicare Helps Pay Cost of Blood
PRIVATE CONTRACTS
69(2)
Private Contracts with Physicians
PART C: MEDICARE ADVANTAGE 71(10)
DEFINITION
71(2)
Medicare Advantage Defined
Health Maintenance Organization
Private Fee-For-Service Plan
Provider-Sponsored Organization
Religious Fraternal Benefit Society Plan
ELIGIBILITY, ELECTION, AND ENROLLMENT
73(1)
Enrollment Process
Enrollment Periods
Beneficiary Information
BENEFITS AND BENEFICIARY PROTECTIONS
74(3)
Basic Benefits
Standards of Protection
Antidiscrimination Rules
Disclosure to Enrollees
Access to Services
Quality Assurance Program
Grievances
Provider Participation Rules
Billing Limits
PREMIUMS
77(1)
Proposed Premiums
Other Premium Rules
CONTRACTS WITH MEDICARE ADVANTAGE ORGANIZATIONS
78(1)
Contracts with Health Care Financing Administration
MEDIGAP INSURANCE PROGRAM
79(2)
Medigap Insurance Rules
Special Protections
PART D: PRESCRIPTION DRUG INSURANCE 81(42)
Prescription Drug Insurance Defined
Effective Date
Who Is Eligible
Benefits of Medicare Drug Discount Card
Cost of Medicare Drug Discount Card
Benefits of Prescription Drug Insurance
Cost of Prescription Drug Insurance
Employer Must Notify Medicare-Eligible Individuals
MEDIGAP INSURANCE
85(12)
Defined
Open Enrollment Period
Medigap Insurance for Medicaid Recipients
Federal Standards for Medigap Insurance
Additional Benefits
Twelve Standard Policies
Medicare SELECT Policies
Choosing the Right Policy
Medicare Advantage Program
Rules for Selling Medigap Insurance
Shopping for Medigap Insurance
HOW TO SUBMIT CLAIMS AND APPEALS
97(1)
CLAIMS PROCEDURE
97(2)
Hospital Insurance Services
How to Submit Medical Insurance Claims
Itemized Bills
Death of Person Filing Claim
Time Limit for Filing Claim
Where to Send Claims
Prompt Payment
APPEALS PROCEDURE
99(6)
Right to Appeal Decision on Claim
How to Appeal Medical Insurance Claim Decision
Review by Medicare Carrier
Hearing with Medicare Carrier
How to Appeal Hospital Insurance Claim Decision
How to Appeal All Other Hospital Insurance Claims
How to Appeal HMO Decisions
Protection if Organization Ceases To Provide Benefits
MEDICAID
105(1)
OVERVIEW
105(1)
Medicaid Defined
Expenses Paid by Federal Government
MEDICAID ELIGIBILITY
106(3)
Groups Covered by States
SSI States
Optional Coverage
MEDICAID SERVICES
109(2)
Basic Services
AIDS
Optional Services
PAYMENT UNDER MEDICAID
111(2)
How Providers are Paid
Amount and Duration of Services
Medicare Coverage
LONG-TERM CARE
113(1)
Medicaid Coverage
EXEMPT INCOME AND RESOURCES
114(1)
Income and Resources Recipient Can Keep
SPOUSAL IMPOVERISHMENT
115(2)
Income
Resources
Income Eligibility Requirements
Post-eligibility Treatment of Income
MEDICAID TRANSFER RULES
117(1)
Transfer of Property to Meet Eligibility Requirements
TRUSTS
118(2)
Use of Trusts
Exceptions to Trust Rule
ESTATE RECOVERIES
120(1)
State Recovery of Medicaid Expenses
DISCRIMINATION
121(1)
Nursing Homes
MANAGED CARE
122(1)
Changes to Medicaid Program
APPENDICES 123
Appendix A Table of Medicare Benefits
123(2)
Appendix B What Medicare Does Not Cover
125(2)
Appendix C Example of Medicare Benefits
127(2)
Appendix D Fiscal Intermediaries
129(2)
Appendix E Medicare Carriers
131(2)
Appendix F Medicare Quality Improvement Organizations (QIOs)
133(2)
Appendix G Durable Medical Equipment Regional Carriers
135(2)
Appendix H Insurance Counseling - General Information
137(2)
Appendix I State Agencies on Aging
139(4)
Appendix J Centers for Medicare & Medicaid Services
143(2)
Appendix K Medicare Advantage PPO Regions
145

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