Medicare explanation as a letter to Mr.smith   Leave a comment

Congratulations, Mr. Smith,

Upon reaching your 65th birthday and working at least ten years with a Medicare paying employer and you being a permanent citizen you qualify for the United States Medicare healthcare program. You have to apply for the coverage if you’re not already receiving social security benefits, railroad retirement Benefits or disability social security benefits. Medicare Mr. Smith has four different programs, Part A, Part B, Part C, and Part D.

Part A no cost, the program covers inpatient care in an acute care hospitals and skilled nursing facilities, hospice care and some home health services. Simply, explained the hospital costs.

Part B (monthly premium) and you pay more if your individual income exceeds $80,000, $160,000 with a combined income.

The Part B plan covers physician services, outpatient hospital care, and other services not covered by Medicare. Simply put physician expenses are covered. Mr. Smith, Part B has deductibles and coinsurance payments, their listed below:

  • $135 annual deductable.(2009)(Placeholder1)
  • 20% of Medicare approved amount after the deductable is met.(Placeholder2)
  • 20% of all occupational, physical and speech-language therapy services.(Placeholder3)
  • 20% of the Medicare-approved amount for Durable Medical Equipment(Placeholder4)
  • 50% for most outpatient mental health care.(Placeholder5)
  • First three pints of blood plus 20% of the Medicare-approved amount for additional pints of blood (after the deductable is met).(Placeholder6)

Part C (Monthly premium) Medicare Advantage program, Mr. Smith these programs are Medicare approved health options managed by private companies. Part C includes all Part A and Part B plans coverage. Mr. Smith while with the part C plan you have the option of enrolling in one of these plans:

  • (HMO) A health maintance organization.(Placeholder7)
  • (MSA) A Medicare savings account plan.(Placeholder8)
  • A Medicare special needs plan.(Placeholder9)
  • (PPO) Preferred provider organization.(Placeholder10)
  • (PFFS) A private fee-for-service plan.(Placeholder11)

Mr. Smith, let’s take a few minutes to discuss optional plans they might be beneficial to you. The HMO, and PPO plans are considered coordinated care plans which means the physician make arrangements with other providers or agencies to provide care for you. Mr. Smith in certain regions of the country, private insurance companies offer the PFFS program. The private insurance company receives an amount of money preestablished each month; the provider decides how much it pays for services. The providers are authorized to charge up to 115% of the plan’s payment schedule and the providers are reimbursed with a fee-for-service basis. Chronic illnesses, management of multiple diseases and focus care management can be covered with the Medicare special needs plans that would benefit from the part A and Part B plans. The individuals have limited membership to the plans and the individuals are eligible for both Medicare and Medicaid, have certain chronic or disabling conditions, or reside in certain institutions.

MR. Smith wait on you nap! I have one more part from Medicare to explain, Part D.

Part D Medicare Prescription Drug Coverage covers all the Medicare beneficiaries prescription drugs cost. Yes there is a premium to join, not only that if you wait until your first eligibly you have to pay a penalty. These plans are administered by private insurance companies and other approved private companies. Signing up for Medicare’s HMO plan (Medicare advantage plan) is one, of two ways to obtain prescriptions. Mr. Smith to your benefit the deductibles’ and premiums vary. The other is to join a prescription plan that adds coverage to the original plan. These plans include private-fee-for service plans and Medicare Medical savings Account plans.

That’s it! Mr. Smith all the Medicare four parts are explained above. But wait, the United States has more to offer; these other plans offer the same coverage as Medicare and a few cover prescription drugs. Medicare Cost Plans, Demonstration/pilot program, Programs of All-inclusive Care for the Elderly (PACE).

I’ll explain these programs in more depth below Mr. Smith;

Medicare Cost Plans the medical is handle pretty much the same way as Medicare Advantage Program, the plan is a type of a HMO. Mr. Smith you pay the coinsurance and deductibles of Part A and Part B plans. The Original Medicare Plan covers the services if you receive health care from a non-network provider. Mr. Smith two more options under these choices; A Demonstration/pilot program a few follow the Medicare Advantage Program these programs are designed to test improvements in Medicare payment, coverage, and quality of care. Mr. Smith the last option Programs of All-inclusive
Care for the Elderly (PACE). The program provides services to an individual in the community who lives and receives health care; the services include medical, social, and long term care. Some states the program is an option with both Medicaid and Medicare. I have the four eligibility requirements here; 65 years old, Resident of the area covered by the PACE program, Able to live safely the community, Certified as eligible for nursing home care by the appropriate state agency(Placeholder12)

Ah, Yes Mr. Smith if you are going to have elective surgery your provider has to notify you (Surgical Disclosure Notice) of the out-of-pocket expenses and the non covered procedures if the amount is more than $500. Medicare defines elective surgery as surgery that can be scheduled, is not an emergency and if delayed, would not result in death or permanent impairment of health. Oh there is more Mr. Smith; way back in 1986 an act passed by the Omnibus Budget Reconciliation Act (OBRA) (Placeholder13)passed requirements that must be in writing to the patient; Estimated actual charge for surgery, Estimated Medicare payment, Excess of the provider’s actual charge as compared with the approved charge, Applicable coinsurance amount, Beneficiary’s out-of-pocket expenses.

Mr. Smith there is a chance that the service won’t be covered by Medicare, in this situation an (ABN) advanced beneficiary notice will sent to you. If you sign the ABN, you have to pay the services if Medicare denies the service. The ABN should state why the claim is denied. Hospitals have a different name (HINN) Hospital-Issued- Notices of Noncoverage or Notice of Non coverage (NONC). Whatever you do Mr. Smith don’t sign the ABN if the service denied is never covered by Medicare. Instead you want to sign a (NEMB) Notice of Exclusion of Medicare Benefits. Kind of confusing isn’t it, A ABN is used when the service is sometimes covered but the provider thinks it won’t be for the patient, a NEMB clearly state the service is never covered by Medicare and the patient is responsible for the charges. That’s it Mr. Smith, that’s Medicare. So go choose your plan and sign up.

Works Cited

Green, M. A., & Rowell, J. c. Understanding Health Insurance .

Michell Green, J. C. (2008). Understanding Health Insurance A guide to billing and reimbursement. ny: Delmar Cengage learning.



Posted May 20, 2010 by briandcox in Uncategorized

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: