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Basic Training Module 3Medicare Part BStudy GuidePrint this study guide for your reference while proceeding through the module.Feel free to make notes as desired. At the end of the guide, there is space towrite questions. If your questions are not answered in future modules, presentthem to the trainer at the final in-class module. Be sure to bring all study guidesto class with you.Part B Coverage (3)Medicare Path (3.1) Still with Original Medicare Part B adds medical coveragePart B Coverage (3.2) Services from doctors and other health care providers Outpatient care Home health care Durable medical equipment Some preventive services and other medical servicesMedical Coverage (3.3) Physician services Preventive services Laboratory and x-rays Home health services Mental health servicesBTM03 Study Guide.docxRev: 4/28/22page 1
BTM03 Study Guide.docxInpatient/Outpatient (3.4) Overnight stay in hospital or facility not required Outpatiento Observation—client stays but is not admitted Part B billed Inpatiento Usually Part A billedo Physician and other related charges usually Part B billedHome Health (3.5) Services needed past 100 days Part B, not Part A Care provided without prior stay in hospital or SNF Part B, not Part APart B Drug Coverage (3.6) Anti-cancer drugs Anti-emetic drugs (for nausea and vomiting) Immunosuppressive drugs (for transplants or auto-immune disorders) Erythropoietin (helps production of red blood cells) Parenteral nutrition (through feeding tubes) Nebulizer medications (inhaled) Infusion pump drugs (administered by IV) Certain vaccines (flu, pneumonia, Hepatitis B, tetanus) Other medications administered by a doctor Insulin (through an external insulin pump)CMS Publications (3.7) Your Guide to Medicare’s Preventive Services Medicare & YouBTM03 Study Guide.docxRev: 4/28/22page 2
BTM03 Study Guide.docxPreventive Services – Medicare.gov (3.8) www.medicare.gov What Medicare Covers Preventive and ScreeningServiceso Displays: how often covered, eligibility, costs, additionalinformationPreventive Services Fact Sheet (3.9)Part B Costs (4)Introduction (4.1) Original Medicareo “Fee-for-service” – a cost for each service“Medicare Costs” Fact Sheet (4.2)Part B Costs (4.3) Premiumso Everyone pays monthly premiumo Cost can change yearly IRMAAo Known as Income-Related Monthly Adjustment Amounto Amount calculated by SSA from income of past two yearso Income threshold doubled if filing joint tax return Out-of-Pocketo Annual (calendar year) deductibleo 20% co-insurance for most Medicare-approved services Penaltieso Based on number of full twelve-month periods that enrollment wasdelayedo Surcharge is 10% x number of full twelve-month periods for as longas beneficiary has Part BBTM03 Study Guide.docxRev: 4/28/22page 3
BTM03 Study Guide.docx Exampleo John turned 65 in April 2012 and did not have group health coverage.His IEP ended July 31, 2012. He joined Medicare during 2015 GEP. Thisdelay was 28 months. Delay of 28 months full twelve month periods Penalty amount is % x full twelve-month periods % surcharge per month for as long as John has Part B.Medicare Summary Notice (4.4) Sent quarterly by CMS Explains all Medicare claims submitted and benefits received for thequarter Contact number for questions Review carefully for accuracy be aware of Medicare fraud Available online through individual account – www.medicare.govMaking the Most of Your Medicare (4.5) Page 2 of MSNYour Claims for Part B (Medical Insurance) (4.6) Page 3 of MSN What each claim showso Service dateo Provider informationo If service approvedo Amount the provider chargedo Medicare-approved amounto How much Medicare paido How much client may be billedo Letter designations that detail explanations of denied services or ifother insurance companies have been billedBTM03 Study Guide.docxRev: 4/28/22page 4
BTM03 Study Guide.docxFile an Appeal (4.7) Final page of MSN Steps to file an appeal SHINE specialty training – Claims and Appeals LiaisonPart B Assignment (5)Medicare Part B “Assignment” (5.2) Definition—provider agrees to accept the Medicare-approved amount asfull payment for approved services and will file the claim for thebeneficiary. Most providers accept assignment always check to be sure If provider does not accept assignment:o Increased cost for serviceso Client may be required to pay full bill and file with Medicare. Reimbursement will be the approved cost of the service.Participating Providers (5.3) Participating providero Signed agreement to accept assignment for all Medicare-coveredserviceso Medicare-approved amount accepted as full paymento Claim filed for the client Non-participating providero Accepts assignment on a case-by-case basiso Client may be required to pay full bill and request reimbursement fromMedicare. Private contract providero Medicare not acceptedo Client’s costs are all out-of-pocket, and Medicare will not reimburse.o Client can switch to a provider who accepts Medicare.BTM03 Study Guide.docxRev: 4/28/22page 5
BTM03 Study Guide.docxExample - Participating Provider (5.4) Full charge Medicare-approved amount 80% of 100 (paid by Medicare) 20% of 100 (Part B co-insurance paid by client) Total out-of-pocket expenses (paid by client)Non-participating Provider – Example #1 (5.5) Non-participating provider, accepting assignment Full charge Medicare fee schedule amount Medicare-approved amount (5% less than fee schedule amount) 80% of (paid by Medicare) 20% of (Part B co-insurance – paid by client) Total out-of-pocket expenses paid by clientNon-participating Provider – Example #2 (5.6) Non-participating provider, not accepting assignment Full charge Medicare fee schedule amount Medicare-approved amount (5% less than fee schedule amount) Limiting charge (15% of ) Total bill (paid by patient at time of service)o Medicare re-imbursemento Client responsibility (already paid) Part B co-insurance (20% of ) Limit (15% of )BTM03 Study Guide.docxRev: 4/28/22page 6
BTM03 Study Guide.docxDurable Medical Equipment (6)Definition (6.2) Withstand repeated use Primarily and customarily used to serve a medical purpose Appropriate for use in the homeItems that do not qualify (6.3) Disposableo Ex: Surgical face masks, catheters, incontinence pads Used outside of homeo Ex: Ramp Individual’s convenienceo Ex: Grab bars, portable toilet, bathDMEPOS (6.4) DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, andSupplies DME includeso Walkerso Wheelchairso Power scooterso Hospital bedso Portable oxygen equipment Prostheticso Devices that can replace a missing body part, such as a hand or leg Orthoticso Supportive devices for a limb or torso Supplieso Diabetic supplies such as glucose monitors, test strips, lancets DME supplier must have an order signed and dated by client’s doctorbefore dispensing any DMEPOS items.o Prior approval – necessary to prevent fraudBTM03 Study Guide.docxRev: 4/28/22page 7
BTM03 Study Guide.docxCoordination of Benefits (7)Coordination of Benefits (7.2) Determines which insurance plan has primary payment responsibility Primary payero Insurance that will pay first Secondary payero Pays all or some portion remaining on claim IRS, SSA, and CMS required by law to share information about eachbeneficiary.o Through this network, proper information is shared and coordinationof benefits is accomplished.Sources of Health Insurance (7.3) Several types of health insurance that function as secondary payer Group Health Planso Employer Group Health Planso Federal Employee Health Benefitso Retiree Group Health Plans Military Coverageo VA health benefitso TRICARE For Lifeo CHAMPVA Other Coverageo Indian Health Serviceso COBRAo Liability insuranceo No-fault insuranceo Workers’ CompensationBTM03 Study Guide.docxRev: 4/28/22page 8
BTM03 Study Guide.docxYour Guide to Who Pays First (7.4) CMS Publication 02179o Print out for use with next two slides. 2-page table describing which type of insurance pays first in a variety ofsituations SHINE also has specialty training on Coordination of Benefits.Case Scenario #1 (7.5) Sarah retired from Green Leaf Food Mart. The company offered her aretiree health plan as a supplement to Medicare. In Sarah’s case, whopays first?Case Scenario #2 (7.6) Bo is 68 and works for Mustang Trucking Company. He receives theemployer group health coverage and Medicare. Recently, Bo had a trafficaccident in his personal vehicle for which he incurred medical bills. InBo’s case, who pays first?Module 3 Quiz (7.7)Conclusion (8)The Next Module (8.2) Password:Questions for Training InstructorBTM03 Study Guide.docxRev: 4/28/22page 9
BTM03 Study Guide.docxBTM03 Study Guide.docxRev: 4/28/22page 10
Preventive Services Fact Sheet (3 .9) Part B Costs (4) Introduction (4.1) Original Medicare o "Fee-for-service" - a cost for each service "Medicare Costs" Fact Sheet (4 .2) Part B Costs (4.3) . Secondary payer o Pays all or some portion remaining on claim
