Medicare Health Insurance Complete Guide

Medicare Insurance is a federal health insurance program that provides coverage to eligible individuals 65 or older or those with specific disabilities or end-stage renal disease. It’s important to understand the ins and outs of Medicare Insurance, as it can significantly impact your healthcare expenses and options.

In this article, we’ll review everything you need about Medicare Insurance, including its basics, enrollment, coverage, and more. So, let’s get started!

Table of Contents

• What is Medicare Insurance?
• Medicare insurance Yearly deductible for 2024
• Basics of Medicare Insurance
• Eligibility for Medicare Health Insurance
• Medicare Part B Eligibility:
• Coverage under Medicare Insurance
• Health Insurance Claim Number:
• Carriers or Intermediaries
• Medical Necessity:
• Clinical laboratory Improvement Amendment (CLIA)
• Health professional Shortage Area
• Provider Identification Number (PIN)
• Unique providers Identification Number (UPIN)
  • Difference between PIN and UPIN
• Medicare insuarnce Primary Payer-
• Medicare insurance Secondary Payer (MSP)
• Crossover
• Medicare Managed Care Program
• Medicare insurance Timely Filing Limit
• Medicare insurance Appeal Limit
• Can I have both employer insurance and Medicare?
• How to find Medicare insurance agents?
• FAQs about Medicare Health Insurance
• Conclusion:
• Also Read

What is Medicare Insurance?

Medicare is a federal health insurance program that provides coverage to Americans aged 65 and older. While it covers many medical expenses, it doesn’t cover everything. This is where supplemental insurance comes in.

Medicare insurance Yearly deductible for 2024

The yearly deductible of Medicare Part B for 2024 is $240.00. Medicare Part A deductible is $1,632 per benefit period.

Basics of Medicare Insurance

Medicare Insurance is divided into different parts, each covering various aspects of healthcare. Here’s a breakdown of each part:

• Medicare Part A: This part covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. Most people don’t have to pay a premium for Part A if they or their spouse paid Medicare taxes while working.

• Medicare Part B: This part covers outpatient medical care, such as doctor visits, preventive care, and medical equipment. There is a premium for Part B, and it’s based on income.

• Medicare Part C: Also known as Medicare Advantage, this part is an alternative to Original Medicare (Part A and B) offered by private insurance companies. Medicare Advantage plans must cover everything Original Medicare covers but may include extra benefits such as vision, dental, and hearing.

• Medicare Part D covers prescription drugs, and private insurance companies also offer it. There is a premium for Part D, and it’s also based on income.

Eligibility for Medicare Health Insurance

Medicare Insurance is administered by the Center for Medicare and Medicaid Services (CMS) (Formerly known as health care Financing Administration-HCFA) of the US department of health and human services. Medicare is a health program for:

Enrollment in Medicare Insurance is automatic for some individuals, while others need to sign up themselves. Here’s what you need to know:

• If you receive Social Security benefits before turning 65, you’ll be automatically enrolled in Medicare Parts A and B.

• Suppose you need to receive Social Security benefits before turning 65. In that case, you must sign up for Medicare during your Initial Enrollment Period, starting three months before your 65th birthday and ending three months later.

• If you miss your Initial Enrollment Period, you can still sign up during the General Enrollment Period, which runs from January 1 to March 31 each year. However, you may have to pay a higher premium for Part B.

• If you’re still working and have employer-sponsored health insurance, you may be able to delay signing up for Medicare without penalty.

In simple words you are eligible for Medicare if

1. People 65 years of age or older.
2. Some people with disabilities under age of 65.
3. People with end stage renal disease (Permanent Kidney failure requiring dialysis or a transplant)

Medicare insurance pays 50% for mental services, 80% for physician fee and 100% for lab procedures, minus the deductible amount.

Medicare hospital insurance pays for most but not all of a patients’ hospital treatment and related expenses.

Medicare Part B Eligibility:

Medicare insurance Part B is optional and offered to all beneficiaries when they become entitled to Part A. It may also purchased by most persons age 65 or over who do not qualify for premium-free Part A coverage.

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. The monthly premium for Part B for the year 2020 is $ 198.00. This monthly premium is deducted from the social security, railroad retirement, or civil services.

A beneficiary’s Medicare card shows the coverage he/she has Hospital insurance(Part A), Medical Insuarnce(Part B), and the date the protection started.

The deductible must be represent charges for services and supplies covered by Medicare. It also must be based on the Medicare approved amounts, not the actual charges billed by the physician or medical supplier.

Medicare Part B carriers are responsible for reimbursing physician services, outpatient hospital services, durable medical equipment, and clinical laboratory tests.

Coverage under Medicare Insurance

Medicare Insurance provides coverage for a wide range of healthcare services, but it doesn’t cover everything. Here are some things to keep in mind:

• Medicare Part A covers inpatient hospital care but doesn’t cover private rooms, personal care items, or private-duty nursing.

• Medicare Part B covers outpatient medical care but doesn’t cover everything. For example, it doesn’t cover dental care, vision care, or hearing aids.

• Medicare Advantage plans may offer extra benefits beyond what Original Medicare covers, but they may also have restrictions on which healthcare providers you can see.

• Medicare Part D covers prescription drugs, but it doesn’t cover all medications. Each plan has its formulary, which is a list of covered drugs.

Health Insurance Claim Number:

Every Medicare insurance beneficiary is issued a health insurance card from the Social Security Administration. The card contains the individual’s name sex, health insurance claim number(HICN), effective date, and Medicare coverage. HICNs are usually social security numbers with letters known as suffix or prefix. HICNs must be included on all Medicare claim forms related bills, documents, notices and any other communication dealing with Medicare claim because medicare records are organized by these numbers.

Carriers or Intermediaries

Carriers or intermediaries are insurance companies under contract with the Center for Medicare and Medicaid Services (CMS) to administer Part B for the Medicare program. They are responsible for processing claims, computing payments for physicians services, making payments, determining whether claims are covered or not, and informing physicians of any changes in Medicare policy and procedures.

These carriers are generally different from state to state.

Railroad Retirement Medicare  beneficiaries enrolled in Railroad retirement Medicare insurance have a Medicare card with mention “railroad Retirement “ displayed prominently. The identification number has an alpha prefix in front of the nine digit number. Palmetto GBA is the national railroad medicare part B Carrier.

Following Medicare Carriers or intermediaries:

State             Carrier Name

Connecticut- First coast service options

Neew Jersey- Empire Medical

New York Up state- Blue cross/blue shield

New York Queens- Group Health

New York Downstate- Empire Medicare

Medical Necessity:

Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member, are excluded under both Medicare and Part A and Part B. For example , there will be no reimbursement for the rental or purchase of a special hospital bed to be used for the patient in the home unless it is a reasonable and necessary part of the patient in the home unless it is a reasonable and necessary part of the patients’ treatment. This also applies to medically unproven, experimental, or investigational procedures.

Medicare will not reimburse for care provided to a patient in a hospital or skilled nursing facility when it could have been provided at home or in an outpatient faciulity.

To be considered “medically necessary” a treatment must ordinarily meet the following criteria.

• Treatment must be appropriate for the person’s condition.
• The treatment must be recognized as the usual or average treatment for a problem.
• The treatment must not be done to convince the patient.
• The treatment can not be experimental.
• The procedure must be the least type of care possible.

Evaluation and Management (E & M)

E & M services are medical services provided by most physicians for the purpose of diagnosing and treating diseases, counseling, and evaluating patients. E/M services are divided into the following categories.

Category                                      Codes

Office or other outpatient Services

New Patient- 99201-99499

Established Patient- 99211- 99215

Hospital Inpatient Services

Initial Hospital care- 99221- 99223

Subsequent Hospital Care- 99231- 99233

Hospital Discharge- 99238- 99239

Consultation

Office Consultation- 99241-99245

Initial inpatient Consultation- 99251-99255

Follow-up inpatient Consultation- 99261- 99263

Confirmatory Consultation- 99271-99275

Critical care Services

Adult over 24 months- 99291-99292

Nursing facility Services

Assesments- 99301- 99303

Subsequent Nursing facility care- 99311-99313

Nursing facility discharge Services- 99315- 99316

Prolonged Services

With direct patient contact- 99354- 99357

E/M codes describe the intensity of a medical encounter including the risks and complexities associated with the diagnosis and medical decision making.

E/M Billing Guidelines for Medicare Insurance

• Only one hospital visit is payable for the same patient on the same day by the same physician.
• Payment will not be made for an office visit , outpatient visit, and or emergency room visit on the same day as an initial facility visit.
• Administration of a drug on the same day as an office visit is not separately payable(Only bill for the office visit and the drug)
• When hospital admission follows an office visit , home visit, nursing home visit, on the same day , only the hospital admission is covered.
• When a hospital visit is billed with a discharge management code on the same day, only the discharge is payable.
• Venipuncture (HCPCS code G0001) on the same day as an office visit is separately payable.

Consultations

A consultation is a referral by one physician to another physician, normally a specialist in a different field, who will provide advice or a treatment plan but, in most instances, will not render definitive medical care. Example – A radiologist who read films and renders a diagnosis. Medicare will reimburse the consulting physician for the following services.Taking patient’s history, examining the patient, ordering tests needed for evaluation, and preparing a written report containing a diagnosis that becomes part of the patient’s permanent medical record.

Clinical laboratory Improvement Amendment (CLIA)

The clinicl laboratory improvement Amendment of 1988 established quality standards for all laboratory testing to ensure accuracy, reliability, and timeliness of patient test results regardless of where the test was performed. A laboratory is defined as any facility that performs laboratory testing on specimens derived from human for the purpose of providing information for the diagnosis, prevention, treatment of diseases or impairment of, or assessment of health.

Health professional Shortage Area

Physician who rendered covered services in areas where there is a shortage of physicans is known as health Shortage Areas (HPSAs) get incentive payments. These physicians receive an additional 10 % of the 80% of the Medicare insurance allowable charge for both assigned and unassigned claims. Effectve from January 01, 2006, “AQ” modifier must be used for HPSA. Claims with dates of service prior to Jan 01, 2006 must continue to use “QU” modifier for services renderd in an urban HPSA, while a “QB” modifier is used for a rural HPSA.

Provider Identification Number (PIN)

The provider identification number (PIN) is a number that identifies the physician to the carrier. Medicare carrier issues the PIN number to providers, which is also known as the provider’s individual billing number. It identifies on the claim from provided the service to the beneficiary. It allows the provider or the beneficiary to receive payments for claims filed to the Medicare carrier. If the physician bills under a group practice, the number will be the same for all physicians in the group.

Unique providers Identification Number (UPIN)

The UPIN also known as individual identification number, is a national number used to identify the physician/practitioner ordering or referring services. It is required for consultations, radiology services, and laboratory and diagnostic tests. All physicians enrolled in Medicare who order or refer Medicare beneficiary services must receive a UPIN even though they may never bill Medicare directly.

If a UPIN can not be found the following UPINS may be used in item 17a in conjunction with the provider’s complete name in item 17 of the CMS 1500 claim form or electronic claim field equivalent.

RES000- is used by physicians meeting the description of intern, resident of fellow.

VAD000- It is used by physicians serving on active duty in the United States Military and those employed by the Department of Veteran Affairs.

PHS000- It is used by physicians serving in the public health service, including the Indian health Service.

RET000- It is used by retired physicians who have not been issued a UPIN.

Difference between PIN and UPIN

The PIN is used to identify the rendering provider and UPIN is used to identify the referring provider.

Time is taken by Medicare to pay a clean claim-  The claim filed electronically paid approx 13 days and on paper, claim paid approx 26 days.

Medicare insuarnce Primary Payer-

Medicare is primary if

• An individual does not have any other insurance and there is no liability or No-fault coverage.
• An individuals employer sponspered coverage is based on his/her retirement. (This is also called supplement coverage)
• An individual’s only other insurance is privately purchased.(it is not purchased through his/her employer. This is also called Medigap Insurance.)

Medicare insurance Secondary Payer (MSP)

Medicare secondary payer (MSP) refers to situations where the Medicare program does not have primary responsibility for paying a beneficiary’s health expenses because the beneficiary may be entitled to other coverage that should pay primary health benefits.

Given Below are cases when Medicare is the secondary payer

• Individuals who are aged 65 years or older and working with the coverage under an employer sponsored or employee organization group health plan.
• Individuals who are aged 65 yrs or older and coverered by a working spouse’s employer group health plan. The working spouse can be any age.
• Individuals who are under age of 65 yrs, have Medicare because of disability, and covered under a large group health plan (LGHP) because of their current employment or the current employment of a family member.
• Individuals who have Medicare because they have permanent kidney failure and are employment or the current employment of a family member.

Supplemental Medicare Insurance (Medigap)

Medicare does not offer complete health insurance protection. Therefore, private insurance is often needed to fill the gaps in coverage.

Medigap insurance is a private health insurance designed specifically to supplement Medicare’s benefits by filling in some of Medicare’s coverage. A Medigap policy generally reimburses for Medicare approved charges not paid by Medicare because of deductible or co-insurance amounts that the patient is liable for. There are Federal minimum standards for such policies, which states include as a part of their programs to regulate Medigap policies. Medigap policies can have different combinations of benefits, and the policies may vary from one insurance company to another.

Medicare crossover the claim information to Medigap insurance only when the doctor participates with Medicare, obtains authorization and provides the necessary policy information on the patients’s claim.

Some common Medicare Supplementary Plans are

• AARP
• American Family Insurance
• BCBS
• Bankers Life
• Mutual of Omaha
• Golden rule insurance
• Provident Life
• State Farm
• Physician Mutual
• Union Fidelity
• United American Insurance

Crossover

Crossover is an agreement between Medicare insurance and various supplemental insurance companies. The agreement permits Medicare to give supplemental insurance information about claims which Medicare has processed.

When a Medicare claim is finalized, the information is automatically transferred to the supplemental insurer, depending on the specific agreement with the insurer.

Medicare Managed Care Program

Medicare eligible beneficiaries may contract with HCFA approved HMOs for health care if they are

• Enrolled in Part B
• Live in the HMO service area
• Are not receiving ESRD or hospice care

Following are the advantages of having a Medicare HMO

• Medigap Insurance is not required.
• Medicare co-insurance and deductibles are not required to be paid.
• Coverage is received for services which the traditional fee-for-service. Medicare does not cover. Eg- Some HMOs offer benefits such as routine physical exam, eye glasses, hearing aids, prescription, and dental coverage.

Medicare managed care is based on contract between the Center for Medicare and Medicaid service(CMS) and an independent health plan. Costs of medical care shared with both Medicare and the HMO. Medicare continues to pay for services as medical expenses are incurred. The private plan pays the balance due after small co-payments by the member. Coverage varies between plans and companies.

Managed care plans for Medicare beneficiaries are provided by the following carriers.

In New York

• CDPHP
• Health Now
• Well care
• GHI
• Aetna
• Empire
• Health first
• Health Net
• HIP
• Oxford
• United

In New Jersey

• Oxford Medicare Advantage
• Amerihealth 65 standard
• Horizon
• Americhoice of NJ

Medicare insurance Timely Filing Limit

Medicare claim filing limit is 365 days from the date of service (DOS).

Medicare insurance Appeal Limit

Medicare appeal limit is 120 days from initial claim submission.

Can I have both employer insurance and Medicare?

The short answer is yes, you can have both. But it’s not always a good idea, and there are some rules you need to follow. Let’s break it down.

1. Medicare Part A and Employer Insurance

Medicare Part A is the part of Medicare that covers hospital stays. Most people don’t pay a premium for Part A because they or their spouse paid Medicare taxes while working. If you have employer insurance, you can still enroll in Part A at age 65, even if you don’t need it. Part A can help cover some of the costs that your employer insurance doesn’t cover, such as deductibles and copayments.

2. Medicare Part B and Employer Insurance

Medicare Part B is the part of Medicare that covers doctor visits and other outpatient services. Part B does have a monthly premium, which is based on your income. If you have employer insurance, you may be able to delay enrolling in Part B without penalty. But this depends on the size of your employer and the type of insurance they offer.

Here are the rules:

• If you work for a small employer (fewer than 20 employees), you generally need to enroll in Part B when you’re first eligible. Your employer insurance is considered secondary to Medicare, which means Medicare pays first and your employer insurance pays second. If you don’t enroll in Part B when you’re first eligible, you could face a penalty if you enroll later.
• If you work for a large employer (20 or more employees), you can delay enrolling in Part B if you have “creditable coverage” through your employer. Creditable coverage means your employer insurance is at least as good as Medicare Part B. Your employer will let you know if your coverage is creditable. If you have creditable coverage, you can enroll in Part B later without penalty when you lose your employer insurance or when you retire.

3. Medicare Part D and Employer Insurance

Medicare Part D is the part of Medicare that covers prescription drugs. If you have employer insurance that includes prescription drug coverage, it’s important to check if it’s creditable. If it’s not creditable, you may want to enroll in a Medicare Part D plan when you’re first eligible. If you don’t, you could face a penalty if you enroll later. Your employer will let you know if your coverage is creditable.

How to find Medicare insurance agents?

Please view the attached Pdf file of Medicare for contact Medicare Broker or Medicare Agent

FAQs about Medicare Health Insurance

Conclusion:

Medicare Insurance can be complex, but understanding its basics, enrollment, and coverage can help you make informed decisions about your healthcare options. Whether you’re approaching age 65 or have a disability, it’s important to know your options and take advantage of Medicare Insurance’s benefits.

If you’re still unsure about any aspects of Medicare Insurance, don’t hesitate to contact the Centers for Medicare & Medicaid Services or a licensed insurance agent for assistance. With the proper knowledge and guidance, you can make the most out of your Medicare Insurance and ensure you receive the healthcare coverage you need.

Also Read

• What is Medical Billing and Coding

• What is Pre Authorization in Medical Billing

• An Overview of the American Healthcare System

• What is Denials Management in Medical Billing? (Complete Guide)

• Dual Eligibility Medicare Medicaid | Dually Eligible Individuals

• Medicare Advantage vs Medicare: Which is Right for You?

• Obama Care Health insurance- Affordable Care Act