Medicare

Link to Article: https://www.medicalbillingandcoding.org/medicare-medicaid

Created in 1965 with the passage of the Social Security Act, Medicare provides health coverage to American citizens 65 years of age or older, and to citizens with certain debilitating diseases.

The basic principle of whether Medicare does or does not cover a service depends on whether the service is “medically necessary.” This necessity is affected by federal laws, national regulations, and local coverage decisions.

The program itself is divided into four sections, or Parts. It’s easier to understand Medicare when we break it up into these four Parts. Each of these Parts has its own set of monthly premiums, and coverage under these often comes with a fixed deductible as well.

• PART A

  Part A is confined mostly to inpatient services. This coverage may extend from overnight stays based on pressing medical concern all the way to hospice care and other long-term stays in a hospital or nursing facility. In order to contain costs and encourage higher quality healthcare, Part A comes with a number of restrictions and criteria. For instance, if a patient needs to return to a hospital within 30 days for an identical procedure, Medicare will not pay the provider for this service.

• PART B

  Part B provides medical insurance for procedures and services not covered in Part A. This includes physician services like x-rays and some kinds of nursing care, along with durable medical equipment like canes and walkers (which you may remember from HCPCS). Along with Part A, Part B of Medicare makes up the basic Medicare coverage package.

• PART C

  Also known as the Medicare Advantage plan, Part C allows Medicare subscribers to receive the entirety of their coverage through a private organization. Medicare Advantage is offered by private HMO and PPO organizations. Subscription to Part C does not require subscription to Parts A and B. Under the Medicare Advantage, the federal government reimburses the private payer, and no claims are filed to Medicare under this program.

• PART D

  The most recent addition to the Medicare, Part D was instituted after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Part D provides coverage for prescription drug costs during healthcare. Patients must actively enroll in Part D (and thus pay its monthly premiums) if they are to receive coverage from this portion of Medicare.

In order to qualify for Medicare benefits, a person must be: 65 years of age; a United States citizen; and be enrolled in Social Security. Medicare makes exceptions for persons under 65 with end-stage renal failure (which requires regular dialysis treatment), and persons under 65 who have other certain disabilities or illnesses (like Lou Gehrig’s Disease).