The
Part C program is a voluntary program providing options to enroll in a Medicare managed care program. The Part C program was also called Medicare+Choice. In 2003, Congress renamed the Part C program the Medicare Advantage program.
Understanding Medicare Managed Care
Individuals can choose to enroll in the Part C program by enrolling in a Medicare Advantage health plan (also called a managed care organization or MCO) as an alternative to receiving Part A and Part B benefits through traditional Medicare. Medicare beneficiaries are not required to enroll in Medicare Advantage health plans. What is managed care? Managed care is a way of getting Medicare services through a health plan that coordinates many aspects of your care. Instead of finding your own doctors and going to see any doctor who accepts Medicare, persons with Medicare Advantage agree to see only providers in the MCO’s network and to follow the rules of the health plan. Why would Medicare beneficiaries choose to enroll in a Medicare Advantage plan? Medicare Advantage health plans attract Medicare beneficiaries by promising better service and, in some cases, reduced cost-sharing or additional benefits that traditional Medicare does not cover. What are important issues for people with disabilities to consider? People with disabilities often have complex needs that can be difficult to address by health care programs that provide services to mostly healthy people. Some features of managed care, however, create special challenges for people with disabilities. One of the key features of managed care plans is that they frequently limit beneficiaries to a closed network of providers. Since there are often only a few qualified providers with the specialized skills for and experience in treating people with specific types of disabilities in a community, closed networks create a risk that people with disabilities will not have access to all of the types of providers they need, or they may not be able to continue seeing their current doctor. For additional information, see the Kaiser Family Foundation’s website resources on Medicare Advantage. |
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Does Medicare cover prescription drugs?
Congress has recently enacted a new voluntary Medicare Part D program to provide a Medicare outpatient prescription drug benefit. This new benefit will not be available until January 1, 2006. Until then, there is an interim Medicare-approved drug discount card and transitional assistance program. The new law also includes other changes for beneficiaries, including new preventive benefits, increases in the Part B deductible (beginning in 2005); and, beginning in 2007, increases in the Part B premium for beneficiaries with incomes over $80,000 (single) and $160,000 (couple).
Beginning June 2004 (and ending by January 2006), Medicare beneficiaries have access to Medicare-approved drug discount cards, estimated to produce savings of 10 percent to 15 percent overall, although no minimum discount is required. Enrollees can sign up for only one Medicare-approved card per year. For beneficiaries with incomes below 135 percent of poverty ($12,569 for a single person or $16,862 for a couple in 2004) 2 who do not have private or Medicaid drug coverage, the government provides $600 per year for drug expenses in 2004 and 2005 and pays the annual discount card enrollment fee.
Medicare will pay for outpatient prescription drugs through private plans beginning in January 2006. Beneficiaries can remain in traditional Medicare and enroll separately in a private prescription drug plan, or they can enroll in a Medicare Advantage plan that also covers prescription drugs.
Under the standard benefit, beneficiaries in 2006:
- Pay the first $250 in drug costs (deductible).
- Pay 25 percent of total drug costs between $250 and $2,250.
- Pay all drug costs between $2,250 and $5,100 in total drug costs.
- Pay either $2 for generics and $5 for brand drugs or 5 percent of total drug spending (whichever is greatest) for all drug spending greater than $5,100 in drug spending. Back to the Top
What are some gaps in Medicare’s benefits package?
While Medicare is a major payor for health care services, it has significant gaps in coverage, including:
- Outpatient prescription drugs (until Medicare drug coverage starts in 2006)
- Personal assistance services
- Institutional services
- Dental care and dentures
- Hearing aids
- Routine eye care and eyeglasses
- Routine foot care
- Many screening tests
- Bathroom grab bars and similar equipment
Even when Medicare covers a particular service or piece of equipment, it sometimes places restrictions on such coverage that can limit the independence of people with disabilities. These are discussed below. Back to the Top
How do people with disabilities obtain these services if Medicare does not cover them?
Assistance may be available under Medicaid for people with disabilities if their income is low enough. Persons who receive both Medicare and Medicaid are known as “dual eligibles” (see page 39 for more information). For many people with disabilities, Medicaid provides a critical supplement to Medicare, filling in Medicare’s gaps in coverage.
Supplemental insurance is sometimes available, and some Medicare beneficiaries also have access to retiree health benefits provided by their previous employer that supplements Medicare’s benefits package. Medigap, or Medicare supplemental insurance, may also be available to provide supplemental benefits to some people with disabilities who are receiving Medicare. Under federal law, Medicare beneficiaries age 65 and over have a right to obtain Medigap coverage, but the law denies this protection to Medicare beneficiaries under age 65 with disabilities. Only a small number of states require insurers that provide Medigap coverage in their state to offer it to nonelderly people with disabilities.
To learn if Medigap coverage is available to people with disabilities under age 65 in your state, you can contact your State Health Insurance Assistance Program. For contact information, go to www.healthassistancepartnership.org. Back to the Top
What should I know about the skilled nursing facility (SNF) benefit?
After an inpatient hospital stay of three days or more, you may be eligible for services in a skilled nursing facility (SNF). If you receive services in a SNF, Medicare covers a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. The benefit is limited to 100 days. There is no deductible for SNF services; however, you must pay $114 a day for days 21-100. The Medicare SNF benefit will pay for short-term skilled care that you require to recover from being hospitalized for an illness or injury. The SNF benefit may reduce the time you are hospitalized after an illness, injury, or surgery by providing skilled care in a less expensive post acute care setting.
Medicare also pays for medical social work and discharge planning services that can help an individual make the necessary arrangements for leaving a SNF once he or she is able to do so. This can include helping the person find, apply for, and schedule services and supports needed to move out of the facility and live in the community. A medical social worker and discharge planner also can help a person leaving a SNF to arrange for ramps, grab bars, and other needed modifications to make his or her home or apartment accessible and livable and to find a new, accessible home or apartment to move into after leaving the SNF. Back to the Top
What should I know about skilled home health services?
To obtain home health services, a doctor must certify that you need skilled nursing care or therapy services on a part-time or intermittent basis. Medicare defines skilled care as medically reasonable and necessary care performed by a skilled nurse or therapist. Examples of skilled nursing care can include wound care (for example, treating pressure sores, catheterization, or changing a tracheotomy tube).
The physician must send a referral or letter of certification to a Medicare-certified home health agency. After receiving this referral, the home health agency sends a nurse to the individual’s home to evaluate him or her and establish a plan of care.
Under such a plan of care, a beneficiary can receive both skilled care and a limited number of home health aide visits each week. Home health aides can assist a person with such tasks as bathing, dressing, using the bathroom, and eating. Medicare pays for this assistance but only when the individual has an underlying skilled care need. In other words, the Medicare home health benefit does not pay for home health aide services for those whose sole need is for personal assistance with the types of daily activities just mentioned.
There are also other limits on the amount of service you can receive under the Medicare home health benefit. As a rule, services cannot exceed eight hours a day or 35 hours a week. Depending on an individual’s need, Medicare home health services can be provided for only a few days or over a period of several years if these basic qualifying requirements continue to be met.
Medicare pays for home health services for any beneficiary who needs skilled nursing care, therapy, and home health aide services due to an acute, advanced (that is, terminal), or chronic (ongoing) condition, as long as the person is “homebound.” Back to the Top
What is the homebound rule?
Enacted in the early 1970s, the homebound rule defines who is eligible to receive Medicare home health services. To be considered “homebound:”
- The individual must have “a normal inability to leave home.”
- Leaving home must require “a considerable and taxing effort by the individual,” typically by relying on a wheelchair, cane, or the assistance of another person.
- The person may leave home for any reason, but most absences outside the home must be of an “infrequent or of relatively short duration.”
The law also specifically permits an individual to be absent from his or her home, at any time, to receive health care or to attend adult day care or religious services.
The third criterion is often applied in a restrictive manner by home health agencies and/or Medicare fiscal intermediaries. Such entities sometimes try to require that those receiving home health services will be discharged and found not to need skilled care if they leave home for any reason other than a limited number of visits for a few specific purposes, such as going to a doctor. But, this interpretation is at odds with the actual language of the law, which allows individuals to leave home for any reason of their choice so long as it is for an “infrequent or of relatively short duration.”
Another reason why the homebound rule is often interpreted in a restrictive manner is that deciding when an absence from home constitutes one that is of an “infrequent or of relatively short duration” can only be done in a very subjective and arbitrary way. Back to the Top
What must someone do to get Medicare to cover home health services?
If you are in the hospital: when you are told that you will be discharged from the hospital, ask to speak to a discharge planner or social worker to arrange for an evaluation by a home health agency (HHA). Your doctor may be able to initiate this process for you.
If you are at home: ask your doctor to contact a home health agency to request an evaluation. If the HHA believes that you are eligible, it can work with your doctor to develop a “plan of care.” Back to the Top
What is Medicare’s policy for covering durable medical equipment (DME)?
Hospital and SNFs provide medical equipment to individuals who are admitted to their facilities. To receive coverage for DME outside of a hospital or SNF, however, you must participate in the Part B program. The DME benefit category covers a broad range of items needed by people with disabilities, such as wheelchairs, augmentative communication devices, and glucose monitors. Medicare’s DME benefit also covers orthotics and prosthetics (O&P). These devices are considered medically necessary when they replace or support a body part. Certain medical supplies are also covered as DME, including oxygen, catheters, ostomy supplies, and test strips for people with diabetes.
Medicare pays for DME when: - You have Medicare Part B.
- Your doctor prescribes a covered item of DME.
- You need the item or device to function in your home.
- You order the item from a Medicare certified dealer.
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What DME does Medicare not cover?
While Medicare covers many items under its Part B DME benefit, other items are considered items of “personal convenience.” Examples of DME or supplies that are not covered by Medicare include:
- Raised toilet seat
- Shower/commode wheelchair
- Grab bars and other safety equipment for the bathroom
- Hearing aids
- Examination gloves
- Catheters
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Why is DME limited to uses within the home?
Nearly 20 years ago, when Congress created Medicare Part B, it allowed the purchase of wheelchairs and other durable medical equipment (DME) only if they are used “in the person's home.” Since the Part A program already covered DME in hospitals and SNFs, Congress did not want to pay twice for the same benefit. Federal regulations have interpreted this to mean that Medicare Part A pays for DME in hospitals and SNFs, and Part B pays for DME needed in the home, but no part of Medicare pays for DME that helps individuals to live in the community. For example, if a person can use a standard manual wheelchair inside his or her house, but actually needs a lighter weight or motorized wheelchair to be more independent and productive in the home and community, Medicare will still only pay for the standard wheelchair. Back to the Top
What is meant by assignment and how does this affect access to DME?
When a DME vendor is said to accept “assignment,” it means that the provider agrees to accept the Medicare-approved amount as payment in full for the good or service.
Medicare does not require beneficiaries to receive services from providers who accept assignment, but this can be an important way for beneficiaries to limit their costs.
A Medicare-certified supplier who does not take assignment can still sell medical equipment to people with Medicare. They can also charge more than the Medicare-approved amount, but they cannot charge in excess of 15 percent more than the Medicare-approved amount. Medicare-certified suppliers also have the option of taking assignment on a case-by-case basis. It is always worthwhile to ask the supplier if he or she will help you by taking assignment. If the supplier does not take assignment for an item you need, you must pay the full cost up front. The supplier then submits a claim to Medicare, and Medicare refunds 80 percent of its approved amount directly to you.
Beware: In this case, you will end up paying 20 percent of the Medicare-approved amount plus any extra amount the supplier charges. Back to the Top
Does Medicare pay for routine maintenance of DME?
No. Medicare does not usually cover routine maintenance of DME, unless the DME is rented. Back to the Top
Does Medicare pay for replacement batteries and tires for power wheelchairs?
Medicare pays for service and maintenance for rented DME. Medicare does not pay for cleaning, testing, or regular DME equipment checkups.
For a particular item of DME, there may be a replacement schedule. For more information, contact a Durable Medical Equipment Regional Carrier (DMERC), which pays DME claims, in your state (http://www.medicare.gov/Contacts/Home.asp). Back to the Top
Does Medicare cover inpatient psychiatric services for people with mental illness?
Medicare pays for some inpatient mental health services, but there is a lifetime limit of 190 days of coverage. Traditional hospitals typically offer limited inpatient psychiatric services. If you seek mental health services from a traditional hospital, however, Medicare will not apply the cost of these services toward the lifetime limit.
Medicare also may pay for partial hospitalization services if the doctor certifies that you need it to avoid more costly inpatient treatment in a hospital. Back to the Top
What outpatient mental health services does Medicare pay for?
Medicare Part B pays for many mental health services. When services are delivered specifically for the people managing their mental health, however, the individual must pay half of the cost. Unlike the 80 percent-20 percent cost-sharing structure for other Medicare Part B services, mental health services require you to typically pay half of the total cost of service.
However, Medicare Part B pays 80 percent of the Medicare-approved amount for some medical services that may be related to your mental health, including:
- Initial diagnostic services;
- Appointments with your doctor to monitor and adjust prescription medication;
- Medical management services for people living with Alzheimer’s and related disabilities; and
- Services provided when participating in a partial hospitalization program.
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MEDICARE APPEAL RIGHTS
What should Medicare beneficiaries do if they are told that Medicare will not pay for a hospital bill or for a Medicare Part A service?
Private companies, known as Medicare claims processing contractors, administer Medicare payments for the federal government. Beneficiaries can file an appeal with a Medicare claims processing contractor within 60 days of receiving notice that payment for a claim is being denied. For individuals to protect their legal rights, they must read and save all correspondence and information they are given related to the services they receive and the payment for these services. If individuals receive a notice that their payment is denied, the notice will include information about how to file an appeal. Individuals must also make sure they follow the appeal rules, including filing an appeal within the time allowed. Back to the Top
Do beneficiaries have rights if they are in the hospital and they are told that they are being discharged before they believe it is medically appropriate?
Yes. Medicare beneficiaries who have been hospitalized have legal protections if they are notified that the hospital or their MCO attempts to discharge them and they do not believe this is medically appropriate. This is called an immediate peer review organization (PRO) review. Medicare relies on PROs to conduct an independent assessment of whether a hospital discharge is appropriate. The right to an immediate PRO review is the same for Medicare beneficiaries in traditional Medicare and for enrollees in a Medicare Advantage MCO.
To request an immediate PRO review, beneficiaries must submit a request in writing or by telephone by noon of the first working day after they have received written notice that the MCO or hospital has determined that their care is no longer medically necessary. The PRO is authorized to review medical records and to receive other pertinent documents from both the MCO and the hospital, and it is required to solicit the views of the enrollee. It is then required to notify the enrollee, the hospital, and the MCO of its decision by close of business on the first working day after it receives all necessary information from the MCO and the hospital.
For Medicare Advantage participants, if a beneficiary files a request for an immediate PRO review on time, and the MCO authorized the initial hospital coverage, then the MCO remains liable for all covered hospital expenses until noon of the calendar day following the PRO decision. If the enrollee wins at this level, the MCO remains liable for hospital expenses until the facility is legally able to discharge the enrollee on the basis that the hospital stay is no longer medically necessary. Back to the Top
What should Medicare beneficiaries do if they are told that Medicare will not pay for a doctor’s bill or for any other Medicare Part B service?
Beneficiaries and Part B physicians and suppliers can file an appeal within six months of receiving notice that payment for a claim is being denied.
Part B disputes for claims totaling at least $100 can be appealed further within six months to claims processing contractors’ in-house hearing officers. Disputes over at least $100 for home health claims and at least $500 for all other claims can be appealed within 60 days to an administrative law judge (ALJ). As with Part A appeals, these ALJ decisions can be appealed within 60 days to the Health and Human Services Departmental Appeals Board, which can turn down appeals or review cases on its own. Within 60 days, these decisions involving at least $1,000 can be appealed further in federal district court. Back to the Top
What should Medicare beneficiaries do if they are enrolled in a Medicare Advantage plan (or MCO), and they are told that the plan will not authorize or pay for a service?
Enrollees should file an appeal in such cases, if, for example, their doctor won’t order a treatment that they think they need and that is covered by Medicare; if they have a problem getting a referral; if their MCO does not approve tests or procedures recommended by their primary care provider; or if their MCO will not approve a second opinion for surgery.
Medicare beneficiaries can appeal a decision by a Medicare Advantage MCO:
- to deny payment for emergency services;
- to deny payment to a provider that is not part of the MCO’s network;
- to refuse to provide a covered service that a Medicare beneficiary believes is medically necessary; or
- to discontinue a service if the beneficiary believes that the service is still needed.
Enrollees may file a grievance if, for example, they believe the MCO’s facilities are inaccessible, inadequate, or in poor condition, or if they did not like the way their doctor treated them. Every Medicare Advantage MCO is required to establish and operate a grievance process that provides for timely hearing and resolution of grievances. Grievances tend to involve issues that are less serious than appeals—which involve actual denials of care—and enrollees do not have a right to an external hearing of their grievances.
1 Includes those with a “serious” chronic condition (i.e., 3 or more ADLs, dementia). Source: One-Third at Risk: The Special Circumstances of Medicare Beneficiaries with Health Problems, Marilyn Moon and Matthew Storeygard, The Urban Institute, 2001.
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| 2 The federal government updates poverty guidelines annually. At the time of publication, poverty guidelines for 2005 were not yet available. To find the latest poverty guidelines, go to http://aspe.hhs.gov/poverty/poverty.shtml. |
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