Medicare Basics

When we talk about "Original Medicare", "Traditional Medicare" or "Medicare Fee for Service," they are all acronyms for the federally funded national program that provides medical coverage for the aged (over 65 years old), the disabled, and those with End Stage Renal Disease (ESRD).

Medicare Part A is Hospital insurance

  • Inpatient hospital care including room charges, general nursing care, skilled nursing facilities, home health and hospice care

Medicare Part B is Medical insurance

  • Physician office visits, diagnostic tests and DME/supplies

Medicare Part C is Medicare Advantage (also referred to as Medicare Replacement)

  • Plans vary by region and state
  • The beneficiary continues to pay the Medicare premiums and must be enrolled in both A and B.
  • You are not eligible for a Medicare Advantage plan if you are ESRD

Medicare Part D is Prescription Drug Coverage

When registering a Medicare patient, the information must be keyed in exactly as it is in on the Medicare card or as it is displayed in the Medicare Common Working file through VisionShare.

  • Last Name, First Name, and any Middle Initial
  • Health Insurance Claim Number (HIC Number)
  • Railroad uses prefix, Original Medicare uses suffix
  • Date of Birth

Medicare Advantage Plans include Medicare HMOs, PPOs, Medicare Special Needs Plans and Medicare Private Fee for Service plans. Medicare Advantage members are still considered part of the Medicare program.

There are two kinds of Medicare Advantage Plans: Managed Care plans, sometimes referred to as Medicare HMOs and Private Fee for Service plans. The HMO uses an approved network of Medicare providers. They are often characterized by having a Primary Care Physician requirement that must authorize all referrals to Specialty Physicians and testing as well as referral authorization to an inpatient setting.

The Private Fee for Service plan allows beneficiaries to go to any accepting provider. The Private Fee for Service Payor, rather than Medicare, decides how much it will pay and what the out of pocket is for the services.

Medicare Coordination of Benefits

The Coordination of Benefits (COB) rules for Medicare apply to the Original A and B plan as well as for the Medicare Advantage plans.

Medicare is primary over:

  • Medigap plans (Supplement plans)
  • Retiree plans
  • Medicaid
  • Indian Health Services
  • Employer Group Plans with less than 20 employees when the Medicare entitlement is age
  • Employer Group Plans with less than 100 employees when the Medicare entitlement is Disability
  • Employer Group Plans (including COBRA) for ESRD patients after the 30 month Coordination period
  • COBRA for disabled entitlement

Medicare is usually secondary to:

  • Auto, Workers Compensation or other liability insurance
  • Black Lung benefits
  • Employer Group plans with over 20 employees, when the Medicare entitlement is age
  • Employer Group plans with over 100 employees, when the Medicare entitlement is Disability
  • Veterans Administration coverage when the VA authorizes care at a civilian hospital
  • Employer Group Health plans (including COBRA) for ESRD patients who are within their 30 month coordination period regardless of the employer size