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Medicare Guidelines & Reimbursements

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Advanced Tissue will bill Medicare first for your treatment supplies. Medicare requires every patient that receives services paid by the Medicare program be responsible for the 20% not paid by Medicare. This amount is often covered by secondary insurance. Advanced Tissue will file private insurance claims. However, in the event the patient has no secondary insurance, he or she will be responsible for the balance due.

Eligibility

Age 65+ Any individual receiving social security benefits at the age of 65 is automatically enrolled in the Medicare program (Part A and Part B) starting on the first day of the month in which the individual turns 65. An individual not receiving social security benefits at the age of 65 has to enroll in the program during a designated enrollment period.
Disability An individual receiving social security disability benefits for 24 months is automatically enrolled in the Medicare program.

Coverage

Part A Part A provides coverage for inpatient hospital stays, skilled nursing facility (not custodial or long term), hospice, and home health. There is not a premium attached to Part A coverage.
Part B Services covered under Part B include doctors’ services, outpatient care, and ancillary services. An annual deductible must be met and all services are covered at 80/20. An individual can elect NOT to receive the Part B coverage and will not be held to the premium attached to Part B coverage (standard premium amount for 2015 is $104.90).
Part C Medicare’s version of a HMO or PPO (previously called Medicare + Choice) resulting in a higher premium than Part B and is only available in certain parts of the country.
Part D Medicare’s optional prescription drug program. Numerous types of plans available and all result in additional premiums.
Medigap Medigap plans are Medicare supplemental policies. There are 12 standardized plans each with their own assigned premium. These supplemental plans (depending on the one selected) cover the costs Medicare does not cover such as deductibles, coinsurance, and co-payments.

Medicare Coverage in Skilled Nursing Facilities

Medicare under Part A covers the first 100 days of skilled care in a Medicare certified skilled facility based on criteria being met. Skilled care is defined as care needing skilled nursing or rehabilitation staff to provide observation, treatment, and management of care (such as physical therapy, IV therapy, sterile dressing changes). Medicare pays 100% for days 1-20 and a daily fixed charge is incurred for days 21-100. Below are the criteria that must be met:

  •  Beneficiary must have Part A coverage and available days left in the benefit period (benefit period defined below).
  •  Beneficiary must have had a qualifying hospital stay of 3 or more consecutive days in a hospital not counting the discharge date and entered in to the SNF within 30 days of that hospital stay requiring skilled care related to the hospital stay.
  •  A physician has ordered daily skilled care.

Benefit Period – The benefit period starts on the first day of stay in a SNF and ends 60 days after the end of receiving skilled services. There is no limit to the number of benefit periods.

Exceptions to the Qualifying Hospital Stay – Medicare Part A coverage can kick in after skilled care has ceased without an additional qualifying hospital stay for the following exceptions provided there are available days left in the benefit period.

  •  Beneficiary leaves a SNF and re-enters that facility or another facility within 30 days requiring skilled care again.
  •  Beneficiary stops receiving skilled care while in a SNF and then starts receiving skilled care again within 30 days.

Hospice Coverage

The hospice patient’s Medicare Hospice Benefit is Part A and 100% covered related to the terminal diagnosis. The non-related items, including wound care supplies not related to the terminal diagnosis, will be billed to Part B, Part D/prescription or Commercial Insurance.

For more detailed information regarding Medicare, visit Medicare.gov.

Noridian Medicare

CGS Medicare

Medicare Information

Food and Drug Administration

Medicare Hospice Benefit

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