Medicare Program. Introduction. Terry Lynch, Independent Living Consultant

Transcription

1 RIGHTS & REALITY II Medicare Program Terry Lynch, Independent Living Consultant Introduction It is commonly assumed that reductions in the rates of reimbursement to the providers of Medicare services affect only those providers (for instance, payment cuts affecting home health agencies and hospitals). This is an incorrect assumption. Sometimes, when people s Medicare coverage is denied or terminated, these decisions are made, incorrectly, because of the pressure on providers to limit their Medicare billing. Incorrect denials are also made simply because of provider misunderstanding of Medicare requirements. Understanding your rights to Medicare coverage will help you take steps to prevent and reverse these mistaken decisions. Eligibility is not based on income Medicare is the national health insurance program for all Social Security recipients who are either over age 65 or permanently disabled. Individuals receiving Railroad Retirement benefits and people with end-stage renal disease are also eligible for Medicare coverage. Medicare is not a welfare program. Eligibility is not based on financial need. Procedures should not vary significantly from state to state and coverage is similar to that provided by private insurance companies: it pays a portion of medical costs. Often, deductibles and coinsurance (partial payment of initial and subsequent costs) are required of the beneficiary (person receiving medical services). What Medicare covers Medicare+Choice Medicare has three options called parts : Part A, Part B and Part C. Part A covers inpatient hospital care, hospice care, inpatient care in a skilled nursing facility, and home health care services. Part B covers medical care and services provided by doctors and other medical practitioners, durable medical equipment, and some outpatient care and home health services. Part A is financed largely through federal payroll taxes paid into Social Security by employers and employees. Part B is financed by monthly premiums paid by Medicare beneficiaries and by federal tax revenues. Under Part C, beneficiaries may choose from a variety of insurance plans other than Medicare s original plan. Medicare Part C is sometimes referred to as Medicare+Choice. In Wisconsin, this means choosing to receive your Medicare benefits through a Medicare HMO (Part C) and not through Parts A and B. In order to participate in a Medicare+Choice plan, it must be available where you live. At the date of publication of this guide, in most Wisconsin counties there is no Medicare+Choice plan available, leaving original Medicare as the only Medicare - 63

2 WISCONSIN COALITION FOR ADVOCACY option. Participation in a Medicare+Choice plan is completely voluntary. Even if Medicare+Choice is available in your area, you may still choose to receive your benefits through the original Part A and B program. Parts A and B are the focus of this chapter. Responsibility for claims processing The Health Care Financing Administration (HCFA) oversees the Medicare program at the federal level. It contracts with private insurance companies in each state to process Medicare claims. Ask your medical providers for the names and numbers of these companies or call your county benefit specialist. (Contact your county Department of Human Services/Social Services or Commission on Aging) Keep in mind that your doctor is extremely important in determining whether Medicare will cover each service discussed here, as well as the duration of the service. You need to have a physician who knows you, listens to you, and who will advocate for your Medicare rights. 42 CFR 406 Rights of disabled individuals Medicare Part A: Entitlement and Enrollment There are several ways to become entitled to Part A. Most people become entitled when they reach age 65 and are eligible for Social Security retirement, survivors benefits or Railroad Retirement benefits. Those age 65 or over who are not entitled to Part A because they do not qualify for Social Security benefits may still enroll in the Part A program, but they pay a monthly premium. Disabled individuals under age 65 are entitled to Part A if they are eligible for Social Security Disability benefits. People with end-stage renal failure are also entitled to Medicare Part A benefits. You are automatically enrolled in Part A when you apply for Social Security benefits. If you choose not to begin drawing Social Security benefits at age 65, a separate Medicare application must be submitted at the local Social Security Administration office. 42 USC 1395f(a) 42 USC 1395x(v)(1)(G)(1) Spell of illness coverage Medicare Hospital Coverage Hospital care is covered if the patient can only be adequately treated in a hospital, or if having been hospitalized, the patient then requires a skilled nursing facility (SNF) level of care, and no SNF bed is available. (A SNF level of care means that the patient requires skilled services from a physical therapist or registered nurse, for example, on a daily basis). After paying a deductible, a beneficiary is entitled to Medicare coverage for 90 days of hospital care during each spell of illness. A spell of illness begins when a beneficiary enters the hospital, and does not end until s/he has not been a hospital in-patient for 60 consecutive days or more (or remains in the hospital but does not receive Medicare-covered care for 60 consecutive days). For example: an elderly woman is hospitalized with pneumonia and receives Medicarecovered treatment. After five days she is discharged. A week later she 64 - Medicare

3 RIGHTS & REALITY II fractures her hip and is admitted again to the hospital. She is discharged after ten more days. These ten days are considered part of her original spell of illness because she had not been out of the hospital for 60 consecutive days, even through her in-patient stays were for two different conditions. This woman has 75 days of Medicare coverage remaining for hospital in-patient care during this spell of illness. If she remains out of the hospital for 60 consecutive days (even though she may be in a skilled nursing facility), her current spell of illness ends. If she subsequently returns to the hospital for in-patient care, it is under a new, 90 day spell of illness. (In some rare cases, patients may remain in the hospital after Medicare-covered treatment ends. These non-covered hospital days count toward the 60 consecutive days requirement.) If a beneficiary never gets through 60 consecutive days out of the hospital, s/he then starts using what is called a lifetime reserve. Once exhausted, the lifetime reserve days cannot be renewed. After that s/he is a private pay patient. Consumer problems related to Medicare reimbursement rates Medicare reimburses hospitals at a pre-determined rate for each covered service. The reimbursement for appendicitis, for example, might be set at $2,000. For every patient treated in the hospital for appendicitis the hospital would receive $2,000 in Medicare reimbursement regardless of whether the patient s care actually cost the hospital less, or more. This reimbursement procedure motivates hospitals to discharge patients as early as possible. Many patients believe they have had to leave the hospital too soon. Premature discharge can create significant hazards for frail elderly patients. If you have an indication that Medicare coverage might be cut off before you are well enough to leave the hospital, ask your nurses to work with you and the doctor to obtain coverage for the additional time you need. 42 CFR ; 42 USC Hospitals must provide explanation of Medicare benefits The rules of Medicare hospital coverage are administered by state Peer Review Organizations (PROs). Ask hospital staff or your benefit specialist how to contact the PRO. PROs approve Medicare hospital charges. Sometimes charges are disapproved after the patient is admitted and has received medical care. Hospitals are becoming increasingly concerned about admitting only those patients for whom the PRO will approve coverage. Unless the patient requests PRO review of a hospital s denial of admission, the PRO will never learn that the patient has been denied. This situation has caused significant loss of access to hospital care, particularly for very elderly patients with chronic conditions. At the time of admission, the hospital must provide every beneficiary with a written statement which explains: the rights to benefits for inpatient hospital services and post-hospital services under Medicare; Medicare - 65

4 WISCONSIN COALITION FOR ADVOCACY the circumstances under which the individual will be liable for charges for remaining in the hospital; the individual s right to appeal denials of benefits for continued in-hospital services; and the individual s liability for payment for services if such denial of benefits is upheld on appeal. A hospital may not charge a beneficiary for any services reimbursed by Medicare, even if the hospital s cost of furnishing services to that beneficiary is greater than the amount the hospital received. The hospital may charge the patient only for deductibles and co-insurance, or for services which are not covered by Medicare. The nurses who care for you are your front line allies in the hospital. They are the ones who communicate most often with your physician. Nurses often are an excellent source of information and ideas about how to get through a hospital stay as successfully as possible, and as long as medically necessary. Spell of illness Coverage requirements 42 C.F.R The Skilled Nursing Facility Benefit (SNF) Medicare Part A provides payment for post-hospital care in SNFs for up to 100 days during each spell of illness. A spell of illness begins on the first day a patient receives Medicare-covered skilled nursing facility care and ends when the patient has spent 60 consecutive days outside the SNF, or remains in the SNF but does not receive Medicarecoverable care for 60 consecutive days. (For more information on what spell of illness means, see pg. 64.) If the patient s condition meets Medicare coverage requirements, the patient is entitled to full Medicare coverage for the first 20 days of SNF care. From the 21 st through the 100 th day, Medicare pays for all covered services except for a daily co-insurance amount. For a patient to be eligible for Medicare covered services in a SNF: 1. A physician must certify that the patient needs SNF care. 2. The patient must have been hospitalized for at least 3 days prior to admission to the SNF and must generally have been admitted to the SNF within 30 days of the hospital stay. 3. The patient must require daily skilled nursing care or rehabilitation. 4. The care the patient needs must, as a practical matter, only be available in a SNF on an inpatient basis. For assistance with eligibility or other issues, contact the Board on Aging and Long Term Care (BOALTC) Ombudsman program at Medicare

5 RIGHTS & REALITY II Examples of skilled services Examples of skilled services covered by Medicare are: overall management and evaluation of care plan; observation and assessment of the patient s changing conditions; Levin tube and gastrostomy feedings; ongoing assessment of rehabilitation needs and potential; therapeutic exercises or activities; and/or gait evaluation and training. The requirement that a patient receive daily skilled services will be met if skilled rehabilitation services are provided five days per week. The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed (patients do not have to have potential to return to the way they were before ). Your rights to appeal decisions 42 CFR Medicare regulations restrictively interpret the skilled care and other coverage requirements. Coverage for skilled nursing facility care has, therefore, become exceedingly difficult to initially obtain. The appeal rights provided for SNF and other Part A Medicare claims, however, are extensive. Many cases appealed to reconsideration, the first level of appeal, are successful. Most cases brought to the second level of appeal, an Administrative Law Judge hearing, result in gaining additional coverage. If the nursing home issues a notice saying Medicare coverage is not available and the patient seems to satisfy the criteria above, ask the nursing home to submit a claim for a formal Medicare coverage determination. The nursing home must submit a claim if the patient or representative requests one. The patient is not required to pay until s/he has received a formal determination from Medicare. 1 Don t be satisfied with Medicare determinations which unreasonably limit coverage; appeal for the benefits the patient deserves. It will take some time, but you will probably win your case. Prohibition on advance payment 42 CFR Medicare law and regulations prohibit nursing homes from requiring an advance payment unless it is clear at time of admission that Medicare will not cover the care to be provided. It can only be clear at the time of admission that the person will not receive Medicare coverage if the person had received the full 100 day benefit per spell of illness or had not applied within 30 days of a three day hospital stay. Otherwise, a no coverage decision may be based only on an assessment of the person s specific needs. Note: Home health care and hospice care coverage will be discussed later in this chapter. There are very specific and confusing requirements associated with what is covered by Medicare and what is not. These can even be confusing to attorneys. Therefore, it is often advisable to use the services of elder law experts as referenced in this chapter. Medicare - 67

6 WISCONSIN COALITION FOR ADVOCACY Eligibility of legal immigrants 42 CFR CFR CFR Preventive services Balanced Budget Act of 1997 Coverage exclusions Medicare Part B Entitlement It is not necessary to be eligible for Social Security in order to enroll in Medicare Part B. An individual is eligible for Part B if s/he is entitled to Part A benefits or is at least 65 years old and is a resident of the United States who is either a citizen of the United States or an immigrant lawfully admitted for permanent residence. A legal immigrant must have lived in the United States for five years immediately before the month of application. Enrollment Enrollment in Part B is optional. Everyone entitled to Part A benefits is automatically enrolled and covered for Part B benefits without making application, unless they indicate that they do not want to be enrolled. If an eligible individual declines automatic enrollment, then decides to enroll in Part B later, an application must be filed with the Social Security Administration (SSA) or HCFA during Part A and B enrollment periods. Check with your local SSA office for the details. (For information as to your closest SSA office call ) Benefits Under Part B The major benefit under Part B is payment for physicians services. Other services include: some home health care; diagnostic x-ray tests, and other diagnostic tests; durable medical equipment (includes iron lungs, oxygen tents, hospital beds and wheelchairs); prosthetic devices; ambulance services; some physical therapy, occupational and speech therapy services; outpatient rehabilitation facility services; institutional and home dialysis services, supplies and equipment; ambulatory surgical center services; psychologist services; and/or therapeutic shoes for patients with severe diabetic foot disease. Part B also covers preventive services including: influenza, pneumococcal, and hepatitis B vaccines; some mammography screening, some pap smear screening, breast exams and pelvic exams; and some other preventive services including colorectal cancer screening, diabetes training tests, bone mass measurements, and prostate cancer screening. Medicare Part B coverage is fairly comprehensive but far from complete. Certain items and services are excluded from coverage. They include: custodial care, such as help with bathing and dressing; prescription drugs which do not require administration by a physician; routine physical checkups; eyeglasses or contact lenses in most cases; hearing aids and examinations for hearing aids; most dental services; and routine foot care Medicare

7 RIGHTS & REALITY II Reasonable charge Medicare assignment Wisconsin Partner Care program Billing for Part B Services A major problem with Medicare Part B coverage is the difference between the cost of medical items or services, particularly physicians services, and the Medicare approved reasonable charge. When an item or service is determined to be coverable under Medicare, it is reimbursed at 80% of the reasonable charge for that item or service. The patient is responsible for the remaining 20%. Unfortunately, the reasonable charge, a rate set by Medicare, is often substantially less than the actual charge to the patient. This results in the patient being left with out-of-pocket expenses greater than the 20% of the reasonable charge. One way to reduce out-of-pocket expenses is to receive services from health care providers who accept Medicare assignment. This means that the provider agrees to accept Medicare s approved amount as the maximum allowable charge for each service. If a health care provider does not accept assignment, a limiting charge of 115% applies. This means the provider cannot charge more than 15% over the Medicare approved amount. (See pg. 74.) The Wisconsin Partner Care program helps some Medicare beneficiaries reduce their costs. To see if you are eligible contact your senior center, your county benefit specialist, or the Coalition of Wisconsin Aging Groups, CFR , , The Medicare Home Health Benefit Eligibility Medicare covers home health services in full, with no required deductible or co-payments. Services must be medically necessary and reasonable and the following criteria must be met: a physician has signed or will sign a plan of care; Homebound the patient is homebound. This requirement is met if leaving home requires a considerable and taxing effort which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, etc. Occasional but infrequent walks around the block are allowable; the patient needs physical or speech therapy, or intermittent skilled nursing (from once a day for periods of 21 days at a time, if there is a predictable end to the need for daily nursing care, to once every 60 days); and the home health care is provided by, or under arrangement with, a Medicare-certified provider. Medicare - 69

8 WISCONSIN COALITION FOR ADVOCACY HCFA Pub A4 (April, 1989) Specific Services If the triggering conditions described above are met, the beneficiary is entitled to Medicare coverage for home health services. Home health services include: part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; physical, occupational, or speech therapy; medical social services under the direction of a physician and; Part-time or intermittent service part-time or intermittent services of a home health aide. ( Parttime or intermittent services, is defined as skilled nursing and home health aide services furnished any number of days per week so long as they are furnished less than eight hours each day and 28 or fewer hours each week combined, or in some cases, up to 35 hours per week, combined.) Resist that s just the way it is limits on home health services. For example, do not accept claims that aide services in excess of one visit per day, or daily nursing visits cannot be covered. Post-institutional home health benefit Extent of coverage For those who are covered under Parts A and B, coverage of home health services is available under Part A for 100 visits per spell of illness only if the services begin within 14 days of a hospital stay of at least three days or a SNF stay of any duration. This coverage is known as the post-institutional home health benefit. The spell of illness starts with the first day of home health services and ends after the 60 th consecutive day in which the person has not been in a hospital, SNF or home health patient. Part B coverage is available for all home health services not covered under Part A. People who do not meet the prior institutional stay requirement, and those who have received coverage for the maximum 100 visits under Part A are eligible for Part B coverage. Individuals who only have Part A receive all home health coverage under that Part, with or without a prior hospital or SNF stay. Coverage of chronic conditions HCFA Pub A4 (April, 1989) 70 - Medicare Home health services do not have to be provided at home. They may also be provided in Medicare-certified outpatient facilities, rehabilitation hospitals, and SNFs. Coverage should not be denied simply because the person s condition is chronic or stable. Restorative potential is not necessary, meaning that you do not need to show potential for getting back to how you were before, in order to receive home health services. If you require skilled services designed to maintain the status of, or prevent deterioration of, a medical condition or functioning of a body part, you are eligible for Medicare coverage. Remember: physical therapy is a skilled service.

9 RIGHTS & REALITY II In order for you to appeal a Medicare denial, the home health agency must have filed a Medicare claim for your care. You should request in writing that the agency file a Medicare claim, even if agency staff told you that Medicare will deny coverage. If you are told that your maintenance or rehabilitation services are to be terminated, request a written notice. It should contain the reason for the termination and should explain the steps and timelines for challenging the decision. Eligibility criteria Hospice Services: In-Home Care for People with Terminal Illness The Medicare hospice benefit assists people with terminal illness. It helps patients remain at home and remain as active as possible, it provides relief from pain and discomfort (palliative care), and provides comfort and support to patients and their families. This benefit may also be provided in a hospital or SNF in some circumstances. The hospice benefit is for people who: are eligible for Part A; are certified by an attending physician and a hospice medical director as having a life expectancy of six months or less; waive regular Medicare curative services for the terminal condition in favor of palliative and supportive services, and affirmatively elect the hospice benefit through the hospice care provider. Service coverage Generally hospice care includes services that are reasonable and necessary for the comfort and management of a terminal illness. These services may include: physician services; skilled nursing care provided by a hospice nurse; therapy services; prescription drugs for pain management and palliative care; counseling; home health aide and homemaker services. It also includes bereavement counseling for up to a year following the death of a beneficiary. Coverage is available for the level of care which is reasonable and necessary. There is no specific limitation on the number of hours of service, and the patient does not have to be homebound. During periods of crisis Medicare will cover continuous home care, including nursing care, for up to 24 hours a day in order to maintain the patient at home. Inpatient respite care may be covered for up to five consecutive days. This care must be intermittent, non routine and occasional. General inpatient care is coverable only for control of pain or acute or chronic symptom management. Medigap: Supplemental Insurance for Medicare Beneficiaries Medigap is insurance which does what its name implies: it covers many payment gaps in Medicare coverage. It helps keep the costs of your Medicare benefits manageable and affordable. It is essential that Medicare - 71

10 WISCONSIN COALITION FOR ADVOCACY every Medicare beneficiary consider purchasing this supplemental insurance coverage. Medigap policies are sold by insurance agents, and these policies vary considerably in what they offer. The sale of this supplemental insurance is regulated by the federal and state governments. Note: If you have Medicaid coverage, you will probably not need Medigap insurance. If you have questions about this, call your county benefit specialist. Hearing aids/eyeglasses are not covered Coverage gaps in Medicare Parts A and B With the exception of state-mandated Medigap benefits (see below), most Medigap policies will only pay if your health care services were first approved and covered by Medicare. Some, not all, of the gaps in these Medicare benefits are: hearing aids and eyeglasses; patient s deductible and co-insurance costs; hospital services beyond 150 days and SNF services beyond 100 days during each benefit period; physician billing above Medicare-approved charges; and home health services when skilled nursing or therapy are not required. Most prescription medications are not covered by Medicare, but this could change in the future. Basic and mandated benefits Basic benefits: the federal government requires that these benefits be part of every Medigap insurance policy: coverage of Medicare co-pay for hospital days and ; full coverage for hospital days in a benefit period; co-payments for SNF skilled care days ; 175 days per lifetime of inpatient psychiatric care in addition to Medicare s 190 lifetime days; some blood transfusions; and 20% of Part B services (no lifetime maximum). Mandated benefits: Wisconsin law requires all Medigap policies sold in Wisconsin to include: 30 days of coverage for skilled care in a SNF; diabetic supplies and equipment; home health benefits; and chiropractic care. There are also optional riders which may be purchased to cover the costs of some prescription drugs, medical services needed while traveling abroad, Parts A and B deductibles, and some other services. One good policy is all you need 72 - Medicare Issues to consider before buying a Medigap policy One of the most important things to remember is that one good policy is all you need. In addition to other issues, you should consider: how much the premiums cost compared to the coverage you would receive; your need to be hospitalized before Medigap coverage may be provided; flexibility of the policy in paying for in-home services; and what happens if you decide to switch to a Medicare+Choice plan and then want to go back to original Medicare.

11 RIGHTS & REALITY II Where to get more information or make a complaint For more information, including specifics on mandated benefits and optional riders, contact the Wisconsin Insurance Commissioner at or the Medigap Helpline operated by the Wisconsin Bureau on Aging and Long Term Care at You should also contact these agencies if you have a complaint related to your policy or simply want to be sure that coverage decisions are correct. Help for Medicare Beneficiaries with Limited Income The Qualified Medicare Beneficiary (QMB) program helps low-income beneficiaries who are eligible for Part A pay premiums, deductibles and co-insurance. To qualify for QMB your income must be at or below 100% of the federal poverty level, and you must have limited personal assets such as stocks and savings accounts. Once you qualify for QMB, you will not need Medigap insurance to pay for most Medicare premiums, deductibles and co-insurance. However, Medigap insurance may improve coverage of psychiatric services. The Specified Low-income Medicare Beneficiary (SLMB) program assists beneficiaries who qualify for Medicare Part A and have incomes between 100% and 120% of the federal poverty level. As with QMB, you must also have limited personal assets. There are two additional low-income programs which provide some assistance with Medicare costs Qualified Individual Programs 1 and 2 (QI 1 and QI 2). For information on these programs, and for more detail on QMB and SLMB, contact your local Social Security office or your county benefit specialist. Appeal Process for Decisions Regarding Coverage of Services This chapter has been largely devoted to an explanation of your rights under Parts A and B of the Medicare program. If you believe that any of these rights have been unfairly denied, there is a formal appeals process to follow under each Part. If you are age 60 or older, ask your county benefit specialist to help with these appeals. (If you are a participant in the Part C program, also contact your benefit specialist to discuss your appeal rights). All appeals must be in writing Part A Appeals If your appeal to the Peer Review Organization (PRO) to reverse a decision regarding coverage of hospitalization is denied, immediately request a PRO reconsideration of that decision. If coverage is denied in the reconsideration decision, request a hearing before an Administrative Law Judge from Social Security s Office of Hearings and Appeals. Medicare - 73

12 WISCONSIN COALITION FOR ADVOCACY Other Part A Appeals: request a reconsideration by the fiscal intemediary administering Part A or your local Social Security office within 60 days of a negative initial determination. If the reconsideration is unfavorable, your appeal may be eligible for review by an Administrative Law Judge. Part B Appeals Under Part B, you will receive a Notice of Medicare Claim Determination or Medicare Summary Notice regarding each service you receive. If you wish a reconsideration of a claim denial, request the reconsideration by the insurance carrier administering Part B or your Social Security office within 60 days of receiving the claim determination. You have the right to request a hearing by an Administrative Law Judge if you do not agree with the reconsideration. Under both Parts A and Part B appeals processes, there are additional steps available beyond the hearing stage, including a request for court review of a claim dispute. Remember to ask your medical providers or benefit specialist for the telephone numbers of the Wisconsin PRO and insurance companies which process Medicare Part A and B claims. Other Helpful Resources Elder Rights and Benefits 2001, published by the Coalition of Wisconsin Aging Groups (CWAG), Elder Law Center: Coalition of Wisconsin Aging Groups (CWAG) Elder Law Center telephone number: web site: Medicare Advocacy Center web site: This organization has a number of helpful consumer-oriented publications. HFCA Medicare web site: Much of this chapter is taken from, or is an adaptation of, materials produced by the Center for Medicare Advocacy, Inc., Willimantic, Connecticut, We are grateful to the Center for permission to use this material. Some material is adapted from Elder Rights and Benefits, published by the Elder Law Center of the Coalition of Wisconsin Aging Groups. 1. Surassat v. Boxen, (D. Cal. 1989) 74 - Medicare