Medicare

The key to working with Medicare is understanding the system so you know your rights and have the ability to make informed decisions about your care and Medicare coverage.

Medicare is a national health insurance program that helps pay for care in a hospital, skilled nursing facility, home health care, hospice care, doctor's bills and outpatient hospital care.

At least thirty-eight million elderly or disabled Americans are now enrolled in Medicare, a program administered by the Health Care Finance Administration (HCFA), a federal agency within the Department of Health and Human Services - the biggest federal agency in the United States government.

In order to qualify for Medicare, a person must be a citizen or permanent resident of the United States, over the age of 65 and have worked, or the spouse has, for a minimum of ten years in Medicare-covered employment. Two exceptions to the age requirement are a disabled person of any age after two years from the date of onset of the disability of a person of any age with chronic kidney disease.

Whether or not an individual must pay premiums depends on several factors. For one, the individual who is receiving retirement benefits, or is eligible to, from Social Security or the Railroad Retirement Board will not have to pay premiums for what are called Part A benefits which include in-hospital care, skilled nursing facility care, blood coverage, some home healthcare and hospice care. Also, individuals or spouses who had Medicare-covered government employment and individuals under age 65 who have received Social Security or Railroad Retirement Board disability benefits for 24 months or are kidney dialysis or transplant patients will not have to pay premiums for Part A benefits.

For Part B benefits, however, individuals who meet the prior criteria will need to pay a monthly health premium for services included such as preventative medicine and routine medical care.

Some elderly or disabled people have more than Medicare for health insurance. In those cases, Medicare is not always the primary payer. In fact, Medicare is the secondary payer if the applicant is entitled to Workers' compensation benefits, Federal Black Lung benefits, no-fault liability insurance, group healthcare in some circumstances and V.A. benefits. Also, the healthcare provider is required by law to submit the Medicare claim forms on behalf of the patient.



Under Medicare law there are patient rights that must be adhered to by facilities and care providers. Medicare beneficiaries' rights include good quality medical care which involves informed decisions concerning treatment received in hospital and other care facilities. A patient is entitled to written notice of any decision made by a hospital that denies Medicare coverage for hospital services. A reconsideration of denied benefits is also an entitlement and done by a Peer Review Organization. This organization is physician-sponsored under contract with the Health Care Finance Organization. Their mission is to improve the quality of care given to Medicare beneficiaries and ensures they receive quality healthcare services that are necessary for their health. The Peer Review Organization reviews the services provided to individual beneficiaries and determines whether or not the care given meets community and professionally recognized standards of care. When a final decision is rendered by the Peer Review Organization, notification and explanation of the decision is submitted by the Peer Review Organization. If there is the option of further appeals after denial of coverage, that information must be given to the individual in written form.

In a hospital, a patient has the right to receive all hospital care that is necessary for the proper diagnoses and treatment of their illness or injury. When the patient is discharged it must be for medical reasons only and not according to Medicare payments. When decisions are made the patient has a right to know about them and how it affects coverage of services both in and out of the hospital. The Peer Review Organization must provide a written notice of review in the case of hospital care no longer being paid for.

Sometimes, a premature discharge becomes an issue for a Medicare recipient. In these cases, the concerns should be immediately discussed with the doctor, patient representatives, social worker, discharge planner and elder law attorney. Written status must be given as to when a patient becomes liable for hospital costs incurred after refusing discharge.

Any time a Medicare beneficiary does not agree with a Medicare-assigned payment for services given, an appeal is in order. Within six months the appeal needs to be filed and can only be extended for good reason such as an emergency or unexpected illness or accident.

In the instant of the need or desire for a second opinion regarding medical care and treatment, Medicare will pay for that, and a third opinion as well if the first two contradict one another.

In the case of needing to request a review for Notice of Noncoverage when the physician agrees with the hospital's decision, the patient cane make a request for that review by the Peer Review Organization and it should be done promptly after receiving the Notice of Noncoverage.

© High Speed Ventures 2011