Medicare Part A Coverage Guidelines

1
Medicare Part A Coverage Guidelines
2
Q2Administrators Contact Information

• This presentation was created by the
  Q2Administrators training team. If you have any
  questions about the material or Q2A training,
  contact us at
• QIC.Training_at_Q2A.org

3
Course Objectives

• Step 2 (a) of the QICs Adjudication Protocol
  states For each argument that does not involve
  denial as not reasonable and necessary, (the QIC
  must) identify the services at issue and review
  the relevant records and Medicare coverage,
  payment guidelines or Review Criteria.
• The purpose of this course is to provide
  guidelines and reference materials for carrying
  out the step.

4
Course Objectives (Continued)

• After taking this course, you should understand
• Who is eligible for Part A benefits
• The cost of Part A coverage
• The basics of calculating benefits
• Basic Part A terminology
• Part A coverage guidelines
• Payment guidelines
• Review Criteria
• How to look up rules and regulations that govern
  Part A

5
Agenda

• Resources
• Medicare Part A Overview
• Inpatient Care
• Eligibility
• Covered Services
• Reimbursement
• Benefit Periods
• Psychiatric Services
• Skilled Nursing Facility Care
• Eligibility
• Covered Services
• Reimbursement
• Benefit Periods

• Review Criteria
• Home Health Care
• Eligibility
• Covered Services
• Reimbursement
• Benefit Periods
• Review Criteria
• Hospice Care
• Eligibility
• Covered Services
• Reimbursement
• Benefit Periods
• Review Criteria

6
Agenda (Continued)

• Outpatient Hospital Care
• Eligibility
• Covered Services
• Reimbursement
• Community mental health centers
• Other rehabilitation facilities
• Comprehensive outpatient rehabilitation
  facilities

• Rural health clinics
• Federally qualified health clinics
• Renal dialysis facilities
• Review Criteria
• Additional Part A Services
• Dental
• Ancillary
• Out of Country
• Participating and Non-participating Providers
• Discussion/Review

7
Resources
8
Resources

• Much of the material in this presentation is from
  the Code of Federal Regulations (CFR) and CMS
  Internet-Only Manuals (IOMs).
• Do not use this presentation as a manual. See
  Title 42 of the CFR and the IOMs for more
  in-depth information regarding Medicare Part A
  coverage.

9
Federal Register, CFR

• The Federal Register and the CFR contain
  regulations that govern the Medicare program. To
  access
• Go to the CMS Web site http//www.cms.hhs.gov.
• On the left-side menu under the Topics heading,
  click the Regulations link.
• On the CMS and Related Laws and Regulations
  page, scroll down until the Federal Register
  and The Code of Federal Regulations via GPO
  Access links appear on the right side of the
  page.
• The links will take you to the Federal Register
  or the CFR on the Government Printing Office
  (GPO) Web site.

10
IOMs

• To access the IOMs
• Go to the CMS Web site http//www.cms.hhs.gov.
• On the left-side menu under the Topics heading,
  click on the Manuals link.
• Scroll down to the Internet-Only Manuals (IOMs)
  link.
• Click this link to view a table of contents of
  manual topics.

11
Medicare and You Handbook

• The Medicare and You 2005 Handbook is the
  Medicare manual that CMS distributes to
  beneficiaries.
• Go to the Medicare Web site http//www.medicare.g
  ov.
• On the left menu, scroll down to and click on the
  Search Tools link.
• Click the Find a Medicare Publication link on
  the right side of the page. This will take you to
  the Medicare Publications page.
• Select Medicare and You 2005 to view the PDF
  file.

12
Helpful Web Sites

• http//www.firstgov.gov (U.S. Governments
  official Web portal)
• http//www.medicare.gov
• http//www.cms.hhs.gov
• http//medicareadvocacy.org (Center for Medicare
  Advocacys Web site)

13
Additional Resources

• Social Securitys Retirement and Medicare Web
  Page
• http//www.socialsecurity.gov/rm2.htm
• CMS Glossary
• http//www.cms.hhs.gov/glossary/
• CMS Acronyms Glossary
• http//www.cms.hhs.gov/acronyms/

14
Medicare Part A Overview
15
Medicare Part A

• Medicare Part A is also known as Hospital
  Insurance. It is generally provided for
• People age 65 or older
• Most people who are disabled for 24 months or
  more who are entitled to Social Security or
  Railroad Retirement benefits
• People with End Stage Renal Disease (ESRD)

16
Basic Coverage

• Inpatient hospital care
• Skilled nursing facility (SNF) care following a
  hospital stay
• Home health care
• Hospice care

17
Providers

• A provider is an individual or agency that
  performs health care services.
• A provider must be a participating provider in
  order to render Medicare-covered services and be
  reimbursed by Medicare. Participating providers
  sign a provider agreement with CMS.

18
Part A Providers

• Hospitals
• Skilled nursing facilities (SNF)
• Home health agencies (HHA)
• Hospice agencies
• 
  
• Other rehabilitation facilities
• Comprehensive outpatient rehabilitation
  facilities (CORF)
• Renal dialysis facilities
• Rural health clinics
• Community mental health centers (CMHCs)

19
The Cost of Part A Coverage

• Most beneficiaries do not have to pay a monthly
  premium for Medicare Part A because they (or a
  spouse) paid Medicare taxes while they were
  working.
• Most who qualify are automatically enrolled by
  the Social Security Administration (SSA).

20
Part A Cost (Continued)

• A beneficiary may not qualify for premium-free
  Medicare Part A coverage if he or his spouse
• Did not pay Medicare taxes while working
• Did not work long enough (10 years in most cases)
  in Medicare-covered employment

21
Part A Cost (Continued)

• If a beneficiary does not qualify for
  premium-free Medicare Part A coverage, he may
  still be able to get the coverage by paying a
  monthly premium. The amount of the premium
  depends on the length of time the beneficiary
  worked in Medicare-covered employment.
• If he worked for less than seven years in
  Medicare-covered employment, he will pay a higher
  premium than if he worked between seven and 10
  years in Medicare-covered employment.

22
Inpatient Care
23
Eligibility

• Medicare helps pay for inpatient care if the
  following conditions are met
• The beneficiary is entitled to Medicare Part A
• The hospital stay is medically necessary
• The inpatient services provided cannot be
  provided as outpatient services
• The services are not excluded from coverage

24
Covered Services

• Semi-private room
• Meals, including special diets
• Care for kidney donors
• General nursing services
• Drugs and biologicals (vaccines, sera,
  intravenous solutions, dyes for x-rays, etc.)

25
Covered Services (Continued)

• Supplies and equipment
• Blood (after 3-pint blood deductible is met)
• Health care associated with pregnancy
• Certain diagnostic services
• Services of residents and interns
• Rehabilitation services (physical, speech,
  occupational and respiratory therapy)

26
Non-covered Services

• Private room (only covered if medically necessary
  and ordered by a physician)
• Private-duty nursing
• Custodial care
• Personal convenience items like televisions or
  telephones

27
Non-Covered Services (Continued)

• Cosmetic surgery
• Foot care
• Dental care
• There may be exceptions to these exclusions,
  depending on a beneficiarys medical condition
  and the medical necessity of the services.

28
Reimbursement

• Medicare pays for most inpatient hospital care
  under the Prospective Payment System (PPS).
• Under PPS, hospitals are paid a predetermined
  rate based on the diagnosis, surgical procedure
  (if applicable), patients age and discharge
  status. These rates are based on payment
  categories called Diagnosis Related Groups (DRGs).

29
Benefit Periods

• A benefit period is the method of measuring the
  days a beneficiary uses Part A.
• A benefit period covers 90 days, and begins when
  the beneficiary is admitted as an inpatient to a
  hospital. It ends when a beneficiary has been out
  of a hospital or SNF for 60 consecutive days.

30
Benefit Periods (Continued)

• If the beneficiary is readmitted to a hospital
  after one benefit period has ended, a new benefit
  period begins. The beneficiary must pay the
  inpatient hospital deductible (912 in 2005) for
  each benefit period.
• There is no limit to the number of benefit
  periods a beneficiary can use.

31
Benefit Periods (Continued)

• Lifetime reserve days (LTRs) are 60 additional
  days a patient can use after the 90 regular days
  of inpatient services are used up. The patient is
  not required to use LTRs.
• LTRs are not renewable. Once any or all of the
  days are used, they are never available again,
  even with the beginning of a new benefit period.

32
Benefit Periods (Continued)

• Calculating the number of days used in a benefit
  period helps determine
• When benefit periods start and end
• How many coinsurance and lifetime reserve days
  are left for the beneficiary
• The amount the beneficiary will pay to cover the
  deductible and coinsurance

33
Benefit Periods (Continued)

• Beneficiaries are responsible for a deductible
  and possibly coinsurance for each benefit period.
• The deductible is the amount the beneficiary must
  pay before Medicare begins to pay. The inpatient
  deductible changes at the beginning of each
  calendar year.
• The coinsurance is the amount the beneficiary is
  responsible for paying after the deductible is
  met.

34
Benefit Periods (Continued)

• Inpatient coverage for each benefit period is as
  follows
• First 60 days Part A pays for all covered
  services after the beneficiary pays the
  deductible.
• Days 61-90 Part A pays for all covered services
  except the daily coinsurance amount, which is 25
  percent of the current years inpatient
  deductible.
• Days 91-150 The beneficiary can elect to use his
  60 lifetime reserve days. Part A pays all covered
  services except the daily lifetime reserve
  amount, which is 50 percent of the current years
  inpatient deductible.

35
Benefit Periods (Continued)

• When calculating the days used in a benefit
  period
• The date of admission is counted as the first
  inpatient day.
• The date of discharge is not counted as an
  inpatient day.
• If admission and either discharge or death occur
  on the same day, the day is considered a date of
  admission and counted as one inpatient day.

36
Inpatient Psychiatric Services

• Medicare imposes a 190-day lifetime limit on
  services rendered in a freestanding psychiatric
  hospital.
• The 190 lifetime psychiatric days are not
  renewable, even with the beginning of a new
  benefit period.
• The rules regarding regular inpatient benefit
  periods, deductibles, coinsurance and lifetime
  reserve days also apply to inpatient psychiatric
  care.

37
Inpatient Psychiatric Services (Continued)

• Covered services in a psychiatric hospital
  include
• Active treatment (doctor-approved treatment that
  can reasonably be expected to improve the
  beneficiarys condition)
• Non-psychiatric care (When certain conditions are
  met, Medicare covers medical or surgical care a
  beneficiary receives while in a psychiatric
  hospital that is not active psychiatric
  treatment.)

38
Skilled Nursing Facility Care
39
Overview

• A skilled nursing facility (SNF) is a qualified
  facility that has the staff and equipment to
  provide skilled nursing care or skilled
  rehabilitation.
• A rural hospital with fewer than 50 beds is known
  as a swing-bed facility because it can swing
  its beds between a SNF and hospital level of care
  based on its needs.

40
Overview (Continued)

• Skilled nursing care is care that can only be
  performed by, or under the supervision of,
  qualified nursing personnel.
• Skilled rehabilitation services include physical,
  speech or occupational therapy performed by, or
  under the supervision of, a qualified therapist.

41
Eligibility

• Medicare can help pay for a beneficiarys SNF
  care if five conditions are met
• The beneficiary requires skilled nursing or rehab
  services on a daily basis
• The beneficiary must receive the care on an
  inpatient basis
• The services are ordered by a physician

42
Eligibility (Continued)

• The beneficiary must have had a hospital
  inpatient stay for at least three days in a row
  before transferring to a SNF. The day of
  discharge does not count. The beneficiary must go
  to the SNF within 30 days of the hospital
  discharge.
• The beneficiary must require skilled services
  related to the condition for which he was
  hospitalized

43
Eligibility (Continued)

• A physician must certify that the beneficiary
  meets all five conditions at the time of
  admission or soon thereafter.
• Recertification is required no later than the
  14th day after SNF care begins. Subsequent
  recertification is required every 30 days.

44
Covered Services

• Semi-private room
• All meals, including special diets
• Regular nursing services
• Physical, occupational and speech therapy
• Drugs furnished by the facility
• Blood (after 3-pint blood deductible is met)
• Medical supplies, such as splints and casts
• Use of equipment such as a wheelchair supplied by
  the SNF

45
Non-covered Services

• Private room (only covered if medically necessary
  and ordered by a physician)
• Private-duty nursing
• Personal convenience items like televisions or
  telephones
• Services after 100 days per benefit period
• Custodial care

46
Reimbursement

• Medicare pays for most inpatient SNF care under
  the Prospective Payment System (PPS).
• Under PPS, SNFs are paid a predetermined rate
  based on the patients Minimum Data Set (MDS) and
  the Resident Assessment Instrument (RAI).

47
Benefit Periods

• SNF coverage for each 100-day benefit period is
  as follows
• First 20 days Part A pays for all covered
  services.
• Days 21-100 Part A pays for all covered services
  except the daily coinsurance amount, which is
  equal to 1/8 of the current years inpatient
  deductible.
• After 100 days in a benefit period Part A no
  longer covers SNF care, until the beneficiary
  starts a new benefit period.

48
SNF Review Criteria

• Use the SNF Review Criteria chart when
  adjudicating skilled nursing facility appeals.
• The chart includes references to specific
  sections of the CFR and the IOMs.

49
Home Health Care
50
Overview

• A home health agency (HHA) is a facility that
  offers skilled care and other services to
  patients in their homes.
• Medicare pays for home health services under Part
  A or Part B. Claims are processed under Part A.

51
Eligibility

• Medicare Part A pays for care in a beneficiarys
  home if all of the following conditions are met
• The beneficiary requires a skilled service
  (intermittent skilled nursing care, physical
  therapy, speech therapy or continuing
  occupational therapy)
• The beneficiary is homebound
• The beneficiary is under the care of a physician
  who has set up and reviews a home health plan of
  care

52
Eligibility (Continued)

• The physician must review the plan of care with
  the home health agency staff at least every 60
  days. The plan must be reviewed more frequently
  under any of the following circumstances
• The beneficiary chooses to transfer to another
  agency or is discharged and returns to the same
  agency
• There is a significant change in the
  beneficiarys condition
• The patient is discharged early

53
Covered Services

• Skilled nursing care
• Home health aide
• Physical, speech and continual occupational
  therapy
• Medical social workers
• Medical supplies
• Durable medical equipment (copayment required)
• The therapy can be provided on an outpatient
  basis to non-homebound patients who are not under
  a home health plan of care. Physicians must
  recertify the need every 30 days.

54
Non-covered Services

• Around-the-clock care at home
• Most drugs
• Meals delivered to a beneficiarys home
• Custodial services

55
Reimbursement

• Medicare pays for the full cost of services under
  the home health benefit using the Home Health
  Prospective Payment System (HHPPS).
• HHPPS is based on a predetermined amount set by
  the Outcome and Assessment Information Set
  (OASIS).
• OASIS generates a Health Insurance Prospective
  Payment System (HIPPS) code, which indicates the
  predetermined amount to be paid.
• The beneficiary does not pay a deductible or
  coinsurance. A copayment is required for durable
  medical equipment.

56
Benefit Periods

• Home health agency benefit periods (episodes) are
  60 days.
• The benefit periods are unlimited.
• The episode begins when the first billable visit
  is provided.
• The episode ends on and includes the 60th day of
  care.

57
Benefit Periods (Continued)

• The HHA will bill a request for anticipated
  payment (RAP) at the beginning of the 60-day
  episode and a final claim at the end of the
  episode.
• For a beneficiarys initial episode, the HHA
  receives 60 percent of the predetermined amount
  when the RAP is billed. It receives the
  additional 40 percent when the final claim is
  billed.
• For subsequent episodes, the HHA receives 50
  percent of the predetermined amount when the RAP
  is billed and the additional 50 percent when the
  final claim is billed.

58
Home Health Review Criteria

• Use the Home Health Review Criteria chart when
  adjudicating home health appeals.
• The chart includes references to specific
  sections of the CFR and the IOMs.

59
Hospice Care
60
Overview

• A hospice is an agency or private organization
  that supports terminally ill patients who are
  expected to live six months or less. The goal of
  hospice agencies is to care for the patient and
  the patients family, not cure the patients
  illness.
• Hospice agencies provide
• Symptom management
• Pain relief
• Administration of medicine
• Counseling
• Respite care

61
Overview (Continued)

• Hospice care can be provided in
• The beneficiarys home
• A hospice facility
• A hospital
• A skilled nursing facility

62
Eligibility

• Part A pays for hospice care if the following
  conditions are met
• The beneficiary has Medicare Part A coverage
• The beneficiary elects hospice benefits, instead
  of standard Medicare coverage, for the terminal
  illness
• A doctor certifies that the beneficiary is
  terminally ill, with a life expectancy of six
  months or less

63
Eligibility (Continued)

• For an initial certification, if the hospice
  cannot obtain written certification within two
  calendar days, it must obtain oral certification
  within those two days. It must then obtain
  written certification no later than eight
  calendar days after the benefit period begins.
• The hospice must obtain recertification no later
  than two calendar days after a new benefit period
  begins.

64
Eligibility (Continued)

• The beneficiarys election statement must include

• The name of the hospice
• Effective date of the benefit
• A general overview of the benefit
• An explanation of palliative vs. curative
  treatment

• Language stating that the patient is responsible
  for
• Seeking pre-approval for treatment not included
  in the plan of care
• Bills incurred for treatment from a provider not
  contracted with the hospice

65
Covered Services

• Physician services
• Nursing care
• Medical supplies and equipment
• Home health aide and homemaker services
• Social workers
• Counseling for beneficiary and family

• Drugs for symptom control and pain relief
• Physical and occupational therapy
• Speech therapy
• Dietary counseling
• Short-term hospital care

66
Non-covered Services

• Treatment to cure the beneficiarys illness
• Limited costs for outpatient drugs and inpatient
  respite care
• Room and board (for place of residency)
• Care from another hospice that was not set up by
  the beneficiarys original hospice agency

67
Reimbursement

• Hospice care is covered at 100 percent, with the
  exception of limited costs for outpatient drugs
  and inpatient respite care.
• The beneficiary is responsible for
• Five percent of the cost of prescription drugs or
  5 per prescription (whichever is less)
• Five percent of the cost of inpatient respite care

68
Reimbursement (Continued)

• Hospice agencies are reimbursed based on the
  level of care provided. The four levels are
• Routine
• Continuous
• Inpatient respite
• General inpatient care
• A hospice bills separately for an employee
  attending physicians professional services. An
  attending physician not employed by the hospice
  bills his professional services through Medicare
  Part B.

69
Benefit Periods

• The first two benefit periods are 90 days.
• Subsequent benefit periods are 60 days.
• There is no limit on a beneficiarys benefit
  periods.
• A physician must recertify that the patient is
  terminally ill for each benefit period.

70
Hospice Review Criteria

• Use the Hospice Review Criteria chart when
  adjudicating hospice appeals.
• The chart includes references to specific
  sections of the CFR and the IOMs.

71
Benefit Periods Summary
72
Part A Benefit Periods
73
Outpatient Hospital Care
74
Overview

• An outpatient is a person who has not been
  admitted as an inpatient, but receives services
  from a hospital or other provider.
• Medicare offers outpatient coverage to
  beneficiaries who are receiving general nursing
  care services, but not staying at a hospital.

75
Overview (Continued)

• Medicare Part A and Part B work together to cover
  outpatient services.
• Part B benefits pay for outpatient services.
• Part A intermediaries process outpatient claims.
• Since Part B benefits pay for outpatient
  services, beneficiaries are not responsible for
  the Part A deductible. They are, however, still
  responsible for the yearly Part B deductible
  (110 in 2005).

76
Overview (Continued)

• A beneficiary can spend the night in a hospital
  and still be designated an outpatient.
• An example of this situation is when a doctor
  keeps a beneficiary in a hospital overnight for
  observation services.

77
Overview (Continued)

• There are two types of outpatient services
• Diagnostic
• Therapeutic

78
Eligibility

• Part B pays for outpatient services if all of the
  following conditions are met
• The beneficiary has Part B coverage
• The beneficiary has met the Part B deductible
• The beneficiary pays coinsurance or a fixed
  copayment for each service
• A physician, nurse practitioner, clinical nurse
  specialist, or physician assistant certifies the
  outpatient care

79
Eligibility (Continued)

• Certification must be obtained at the time the
  plan of treatment is established, or as soon
  thereafter as possible.
• Recertification statements are required at least
  every 30 days.

80
Covered Services

• Physical, occupational and speech therapy
• Clinical laboratory services billed by hospital
• Preventive services
• Mental health care (if physician certifies that
  inpatient care would be required without it)
• Ambulance transportation (when other
  transportation endangers the beneficiarys health
  and the ambulance is hospital-based)

81
Covered Services (Continued)

• Services in an emergency room or outpatient
  clinic
• Drugs and biologicals not considered
  self-administered drugs
• Physician services
• Observation
• Many other health services and supplies

82
Non-covered Services

• Routine services
• Personal comfort items
• Custodial care
• Cosmetic surgery
• Dental services

83
Reimbursement

• Outpatient hospital services are reimbursed under
  the Hospital Outpatient Prospective Payment
  System (OPPS).
• OPPS was developed so that Medicare would pay a
  predetermined rate for each type of hospital
  service.

84
Community Mental Health Centers (CMHC)

• CMHCs provide partial hospitalization (less than
  24 hours per day) services that include
• Specialized services for children, the elderly,
  individuals who are chronically mentally ill, and
  those who have been discharged from inpatient
  treatment at a mental health facility
• Emergency care
• Psychosocial rehabilitation
• Screening for patients being considered for
  admission to state mental health facilities

85
Other Rehabilitation Facilities

• Medicare also covers services provided at
  freestanding entities that provide either
• Physical therapy
• Speech therapy
• Occupational therapy

86
Comprehensive Outpatient Rehabilitation
Facilities (CORF)

• A CORF must provide at least the following three
  services
• Physicians services
• Physical therapy
• Social or psychological services

87
Rural Health Clinics (RHCs)

• Provide the types of services patients could
  receive in a doctors office, outpatient clinic
  or emergency room
• Must be located in a medically under-served area
  that is not urbanized as defined by the U.S.
  Bureau of Census
• Services may be provided by a physician, nurse
  practitioner, physician assistant, nurse midwife,
  clinical psychologist or clinical social worker

88
Federally Qualified Health Clinics (FQHCs)

• FQHCs provide the same services as RHCs.
• A beneficiary is not responsible for a deductible
  when claims are processed for FQHCs. The
  beneficiary is still responsible for Part B
  coinsurance (20 percent of the billed charges).

89
Renal Dialysis Facilities

• For beneficiaries with permanent kidney failure,
  Medicare covers dialysis treatments administered
  in an approved dialysis facility. Coverage
  includes
• Equipment
• Supplies
• ESRD-related laboratory tests
• Other services associated with treatment

90
B of A Review Criteria

• Use the B of A Review Criteria chart when
  adjudicating outpatient hospital appeals. B of A
  is a common term for services processed by Part A
  intermediaries and paid for by Part B.
• The chart includes references to specific
  sections of the CFR and the IOMs.

91
Additional Part A Services
92
Dental

• When a patient is hospitalized for a dental
  procedure and the dentists services are covered
  under Part B, the inpatient hospital services are
  covered under Part A.
• Although hospitalization for most dental
  services is excluded, hospitalization is covered
  when it is medically necessary to
• Treat fractures of facial bones
• Treat injuries to structures in the mouth that
  require surgery
• Remove tumors or cysts from inside the mouth

93
Dental (Continued)

• If a patient is hospitalized for a non-covered
  dental procedure but hospitalization is required
  to assure proper medical management, control, or
  treatment of a covered service (non-dental
  impairment), the hospitalization services are
  covered.

94
Ancillary

• Ancillary services are services other than room
  and board furnished by the provider. When no Part
  A inpatient payment is made, the provider can
  bill certain services to Part B. Reasons for no
  Part A payment include
• The beneficiarys Part A benefits are exhausted
• Admission was not reasonable and necessary
• A day (or days) of an otherwise covered stay was
  not reasonable and necessary
• The beneficiary is not eligible for Part A
  benefits

95
Ancillary (Continued)

• Billable services include
• Diagnostic x-rays or tests
• Surgical dressings, casts and splints
• Prosthetic devices (other than dental)
• Leg, arm, back and neck braces
• Outpatient physical, speech and occupational
  therapy
• Ambulance transportation to and from a hospital
• Other services

96
Out of Country

• In general, Medicare will not pay for health care
  obtained outside the United States.
• Puerto Rico, the U.S. Virgin Islands, Guam,
  American Samoa and the Northern Mariana Islands
  are considered to be part of the United States.
  Territorial waters adjoining the land areas of
  the United States are also considered part of the
  U.S.

97
Out of Country (Continued)

• Medicare may pay for inpatient hospital services
  received in Canada or Mexico if
• A patient has a medical emergency and the
  Canadian or Mexican hospital is closer than the
  nearest U.S. hospital
• A patient lives in the United States and the
  Canadian or Mexican hospital is closer to his
  home, even if there is no emergency
• A patient is traveling through Canada without
  unreasonable delay by the most direct route
  between Alaska and another state and a medical
  emergency occurs

98
Participating and Non-participating Providers
99
Participating Providers

• A participating provider is an institution
  approved by the Centers for Medicare Medicaid
  Services (CMS) that has agreed to
• Accept Medicares payment based on the reasonable
  cost of the items and services provided
• Not charge the beneficiary for covered items and
  services, except deductibles and coinsurance
• Return any money incorrectly collected

100
Non-participating Providers

• If there is a medical emergency, Medicare may pay
  for services provided in a non-participating
  hospital if that hospital is the closest one
  equipped to handle the emergency. Three separate
  conditions must exist
• An emergency occurs that could result in death or
  serious impairment
• The hospital is a qualified emergency services
  hospital
• The diagnosis or treatment is given at the most
  accessible qualified hospital available and
  equipped to furnish the services

101
Discussion/Review
102
Discussion/Review

• Is it possible to be in the hospital overnight
  and still not be considered an inpatient?

103
Discussion/Review

• Yes. A beneficiary can stay one or more nights in
  a hospital and not be considered an inpatient.
  The physician decides whether or not to admit a
  beneficiary as an inpatient.
• For an inpatient stay, the beneficiary is
  responsible for an inpatient deductible. If the
  beneficiary is an outpatient, he must pay the
  Part B deductible and coinsurance before Medicare
  begins to pay.

104
Discussion/Review (Continued)

• A beneficiary asks, Why do I have to pay another
  Part A deductible? I already paid one this year.

105
Discussion/Review (Continued)

• If a beneficiary has been out of the hospital or
  SNF for more than 60 consecutive days, a new
  benefit period begins. This means the beneficiary
  must pay another Part A deductible.

106
Discussion/Review (Continued)

• What are lifetime reserve days?

107
Discussion/Review (Continued)

• These are days a beneficiary holds in reserve in
  case he has a long illness and needs to stay in
  the hospital more than 90 straight days. Each
  beneficiary has 60 lifetime reserve days that he
  can use whenever he needs them. They can only be
  used once and are not renewable.

108
Discussion/Review (Continued)

• What is the blood deductible? Does a Medicare
  beneficiary always have to pay this deductible?

109
Discussion/Review (Continued)

• The blood deductible is the first three pints of
  blood per calendar year. There are two ways a
  patient can meet the blood deductible
• Pay the fees assessed for the first three pints
• Donate blood to replace what was used or arrange
  for another person or blood-replacement
  organization to do so. A hospital or SNF cannot
  charge a beneficiary for any of the first three
  pints of blood that a beneficiary replaces or
  arranges to have replaced.

110
Discussion/Review (Continued)

• Hospice agencies are paid based on the level of
  care provided. What are the four levels of
  hospice care?

111
Discussion/Review (Continued)

• The four levels of hospice care are
• Routine
• Continuous
• Inpatient respite
• General inpatient