Frequently Asked Questions

Medicare: Medicare is a Federal insurance program. Medical bills are paid from trust funds, which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. It is basically the same everywhere in the United States and is run by the Centers for Medicare/Medicaid (CMS), an agency of the Federal government.

Medicaid: Medicaid is a state assistance program. Medical bills are paid from federal, state, and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a Federal-state program. It varies from state to state. It is run by state and local governments within Federal guidelines. (www.hcfa.gov/F A Q's/answers.htm#fraud1)

2. What types of services are covered under Medicare?

Listed below is general information on what is covered under Medicare Parts A and B. We have also included links to publications which contain detailed information on specific types of care (for example, prevention services and hospice care). You may also want to read the coverage brochure, Your Medicare Benefits.

MEDICARE PART A

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care. You must meet certain conditions.

Medicare Part A Helps Cover Your:

Hospital Stays: Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental health care. This does not include private duty nursing, or a television or telephone in your room. It also does not include a private room, unless medically necessary. Read Medicare and Your Mental Health Benefits for more information on inpatient mental health benefits.

Skilled Nursing Facility Care: Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related three-day hospital stay). Read Medicare Coverage of Skilled Nursing Facility Care for more information.

Home Health Care: Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Read Medicare and Home Health for more information.

Hospice Care: Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in your home. However, short-term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed. Read Medicare Hospice Benefits for more information.

Blood: Pints of blood you get at a hospital or skilled nursing facility during a covered stay.

MEDICARE PART B

Medicare Part B (Medical Insurance) helps cover your doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare Part B premium of $58.70 per month in 2003.

Medicare Part B Helps Cover Your:

Medical and Other Services: Doctors' services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers -- not in nursing homes). Also covers second surgical opinions, outpatient mental health care, outpatient physical and occupational therapy, including speech-language therapy. Read Medicare and Your Mental Health Benefits and Getting a Second Opinion Before Surgery for more information.

Clinical Laboratory Services: Blood tests, urinalysis, and more.

Outpatient Hospital Services: Hospital services and supplies received as an outpatient as part of a doctor's care. Read Your Guide to the Outpatient Prospective Payment System for more information.

Blood: Pints of blood you get as an outpatient or as part of a Part B covered service.

Medicare Also Helps Cover:

Ambulance services (when other transportation would endanger your health).
Artificial eyes.
Artificial limbs that are prosthetic devices, and their replacement parts.
Braces - arm, leg, back, and neck.
Chiropractic services (limited), for manipulation of the spine to correct a subluxation.
Emergency care.
Eyeglasses - one pair of standard frames after cataract surgery with an intraocular lens.
Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare).
Kidney dialysis. Read Medicare Coverage of Kidney Dialysis and Kidney Transplant Services for more information.
Macular degeneration of the eye (age-related) treatment, using ocular photodynamic therapy with verteporfin.
Medical nutrition therapy services for people with diabetes or kidney disease with a doctor's referral.
Medical supplies - items such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies.
Outpatient prescription drugs (very limited). For example, some oral drugs for cancer.
Preventive services. Read Medicare Preventive Services to Keep You Healthy or Women with Medicare - Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam for more information.
Prosthetic devices, including breast prosthesis after mastectomy.
Second opinion by a doctor (in some cases). Read Getting a Second Opinion Before Surgery for more information.
Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners.
Telemedicine services in some rural areas.
Therapeutic shoes for people with diabetes (in some cases).
Transplants - heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions and when performed at approved facilities).
X-rays, MRIs, CAT scans, EKGs, and some other diagnostic tests.

What is not paid for by Medicare Part A and Part B:

Acupuncture.
Deductibles, coinsurance, or co-payments when you get health care services.
Dental care and dentures (in most cases).
Cosmetic surgery.
Custodial care (help with bathing, dressing, using the bathroom, and eating) at home or in a nursing home.
Health care you get while traveling outside of the United States (except in limited cases).
Hearing aids and hearing exams.
Orthopedic shoes.
Outpatient prescription drugs (with only a few exceptions).
Routine foot care (with only a few exceptions).
Routine eye care and most eyeglasses (see exception above for one pair of standard frames after cataract surgery with an introcular lens).
Routine or yearly physical exams.
Screening tests except those listed in Medicare Preventive Services to Keep You Healthy.
Shots (vaccinations) except those listed in Medicare Preventive Services to Keep You Healthy.

3. Can suppliers bill Medicare for delivery and/or shipping of DMEPOS items?

No. Per §5105 of the Medicare Carriers Manual, delivery and services are an integral part of a DMEPOS supplier's cost of doing business. The cost of delivery and service are typically taken into account by suppliers when determining their customary charges. Therefore, these costs are already included in the calculation for fee schedules and allowables.

4. What can suppliers do about other suppliers who routinely tell patients that they will write off the 20% co-payment?

Such activity should be reported to the Benefit Integrity Unit at (877) 867-4852. Routinely waiving the 20% co-payment could be perceived as an enticement to gain Medicare business.

Source: (National Government Services)

5. Can a supplier write off all co-pays for all patients?

Suppliers should only be writing off co-pays for those patients for whom many collection attempts have been made. This should not be a standard business practice.

6. Does the Assignment of Benefits completed by the beneficiary give the supplier the right to view their nursing home files?

The Assignment of Benefits completed by the beneficiary give the supplier the ability to collect medical necessity documentation, submit the claim on the beneficiary's behalf, and receive payment for that service directly from Medicare.