Medicare Handbook, 2013 Edition

To provide effective service in helping clients understand how they are going to be affected by health care reform and how to obtain coverage, pursue an appeal, or plan for long-term care or retirement, you need the latest Medicare guidelines from a source you can trust - the 2013 Edition of Medicare Handbook.

Prepared by experts from the Center for Medicare Advocacy, Inc., Medicare Handbook covers the issues you need to provide effective planning advice or advocacy services, including:

• Medicare eligibility and enrollment
• Medicare-covered services, deductibles, and co-payments
• Co-insurance, premiums, and penalties
• Federal coordinated care issues
• Grievance and appeals procedures
• Face-to-face encounter requirements for home health and hospice care

Medicare Handbook also provides you with coverage rules for:

• Obtaining Medicare-covered services
• Prescription drug benefit and the Low-Income Subsidy (LIS)
• The Medicare Advantage Program
• Durable Medical Equipment (DME)
• Preventive services
• Appealing coverage denials

and an understanding of:

• The Medicare Secondary Payer Program (MSP)
• The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Acquisition Program
• Income-related premiums for Parts B and D

The 2013 Edition has been updated to include information and strategies necessary to incorporate ACA provisions on behalf of people in need of health care.

In addition, the 2013 Medicare Handbook will also help advocates contest limited coverage under private Medicare Part C plans (Medicare Advantage) and understand initiatives to reduce overpayments to Medicare Advantage.

Other Medicare developments discussed in the 2013 Medicare Handbook include:

• Implementation of important provisions of the Affordable Care Act
• Beneficiary rights, when moving from one care setting to another
• Developments in the Medicare Home Health and Hospice Benefits
• Additional information regarding preventive benefits
• Continued changes in Medicare coverage for durable medical equipment

• 1. An Introduction to Medicare Coverage and Appeals
  • History and Overview
  • Financing
  • Administration
  • Enrollment and Eligibility
  • Coverage
  • Medicare Savings Programs
  • The Medicare Appeals Process
• 2. Hospital Coverage
  • Eligibility for Medicare Hospital Insurance (Part A)
  • Application or Enrollment for Medicare Part A
  • Scope of Benefits - Inpatient Hospital Coverage Benefit Periods
  • Medicare-Covered Services
  • Coverage Criteria Explained
  • Limitations on Payment for Services
  • The Medical Necessity Standard for Inpatient Hospital Stays
  • Hospital Payment
  • Utilization Review and Quality of Services
  • Appealing Coverage Denials
  • Denial and Appeal Process
  • How to Develop a Winning Appeal
• 3. Skilled Nursing Facility Coverage
  • Coverage
  • Qualifying Criteria
  • Identifying Coverable Cases
  • SNF Prospective Payment System and Resource Utilization Groups
  • Problem Areas of Concern for the Advocate
  • Pre-Appeals Advocacy
  • Appeals
• 4. Home Health Coverage
  • Coverage
  • Requirements for Coverage
  • Chronic, Stable, and Maintenance-Level Patients
  • Prospective Payment System (PPS) for Home Health Services
  • Claims Submission, Determination, and Appeal
  • The Role of Advocacy
  • How to Develop a Winning Appeal
• 5. Hospice Coverage
  • Eligibility
  • Election of the Hospice Benefit
  • Who May Make an Election for Hospice Care
  • Hospice Admission
  • Patient Rights
  • Hospice Revocation
  • Hospice Discharge
  • Changing Hospice Providers
  • Hospice Services
  • Medicare Rules for Hospice Inpatient Care
  • Medicare Hospice Inpatient Cap
  • Hospice Care for Residents of Facilities
  • Deductibles and Coinsurance for Non-Hospice Care
  • The Appeals Process
  • The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
• 6. Medicare Part B: Supplementary Medical Insurance Benefits for the Aged and Disabled
  • Enrollment and Payment Requirements
  • Covered Medical and Other Health Care Services
  • Medicare Assignment Program
  • Filing Medicare Part B Claims
  • Information About Coverage
  • Appeals
  • Appointments of Representatives and Attorneys' Fees
• 7. Medicare Advantage: Coordinated Care Plans, Private Fee-for-Service, and Other Delivery of Services Options
  • Advantages and Disadvantages of Medicare Advantage Options
  • Guidelines for Considering Medicare Advantage Options
  • Medicare Advantage
  • Medicare Advantage Quality Improvement Program
• 8. Medigap Services
  • Medicare Certification of Policies
  • Standardized Plans
  • High Deductible Plans
  • Medicare SELECT
  • Legislated Policy Changes
  • Consumer Protections
  • Prohibition Against Sale of Duplicate Policies
  • Required Ratio of Aggregate Benefits to Aggregate Premiums
  • Coverage of Preexisting Conditions
  • Dissemination of Information About Medigap Policy Benefits
  • Adding Cost-Sharing to Medigap Policies
• 9. Medicare's Relationship with Private Insurance
  • Employer Group Health Plans
  • Calculation of Medicare Secondary Payment Amount in EGHP Cases
  • Enforcement of EGHP Claims
  • Coordination of COBRA Rights and Medicare
  • MSP Rules Applicable to Medicare Advantage Plans
  • Conditional Payment and Third-Party Recovery
  • MSP Workers' Compensation Recovery
  • MSP Collection Procedures
  • Mandatory Reporting by Insurers
  • Beneficiary Rights to Seek Waiver or Appeal the MSP Recovery Claim
• 10. Dual Eligibility: Issues for Medicare Beneficiaries Also Eligible for Medicaid
  • Profile of the Dually Eligible
  • Summary of Medicaid Eligibility and Medicaid Benefits
  • Universe of Dual Eligibility
  • Enrollment Issues for Medicare Savings Programs Population
  • Access Issues for the Dually Eligible Population
  • Managed Care Issues for Dually Eligible Individuals
  • Programs of All-Inclusive Care for the Elderly
• 11. Prescription Drug Coverage
  • Eligibility for Part D Coverage
  • Choice of Drug Plans
  • The Part D Drug Benefit
  • Enrolling in a Part D Plan
  • Premium and Cost-Sharing Subsidies for Part D Prescription Drugs for Low-Income Individuals
  • Dual Eligibles
  • State Pharmaceutical Assistance Programs (SPAPs)
  • Grievance, Appeals, and Exceptions Processes