Understanding Medicare

Two main ways to get

Medicare coverage, which comes
in four types
Original Medicare (Part A and Part B) or a
Medicare Advantage plan (Part C).
Some people get additional coverage, like
Medicare prescription drug coverage (Part
D) or Medicare supplement insurance
(Medigap)
The Four types are Medicare A, Medicare B,
Medicare Advantage Plan (Part C) and a
prescription plan (Part D)
Medicare Part A

Hospital insurance
Medicare provides this coverage
Generally the patient pays a deductible and coinsurance for part A
services. If they choose to buy a Medicare supplement insurance
(Medigap) that policy may cover some of those costs.
MBS Cannot bill for someone in a Medicare Part A stay. The patients must
be put into the Part A Company. (MBS Part A)
Part A Covers

Hospital Care
Skilled Nursing Facility Care
Nursing Home Care (As long as custodial care isnt the only care needed)
Hospice
Home Health Services
Medicare Part B Covers

Medicare Part B covers:

Lab Tests
Surgeries
Doctor Visits
DME Supplies which include
Urological Supplies
Ostomy supplies
Trach supplies
Enteral Feeding Supplies
Wound Care supplies
Covered services

Medicare covers supplies based on three things:

Federal and State Laws
National Coverage Decisions made by Medicare about whether something is
covered
Local Coverage Decisions made by companies in each state that process claims for
Medicare. These companies decide whether something is medically necessary and
should b covered in there area.

MBS can bill for someone in a part b stay as long as the supporting doc needed to
substantiate the product is present.
Dysphagia
Nutrient Doc
Pump Doc
Medicare Part B Covers

Medically Necessary Services: Services or supplies that are needed to

diagnose or treat your medical condition and that meet accepted
standards of medical practice
Preventative Services: Health Care to prevent illness like the flu or detect it
at an early stage, when treatment is most likely to work best.
Medicare Part B does not cover products for a resident who is in a
Medicare Part A stay. Part B starts when the Part A benefit period ends.
Medicare Part B is an 80/20 plan. Medicare pays 80% of the allowed
amount of an item, while the patient is responsible for the 20% copay.
Assignment means the provider agrees to accept the Medicare approved
charges for a service or product.
Medicare Part C

Medicare Advantage plans are commercial insurance company policies

that cover multiple segments of Medicare. It may combine all Medicare
benefits into one policy, A B & D. Because these plans are policies held by
insurance companies, they can have closed networks, meaning they are
not accepting new providers.
If MBS is in network with an Advantage plan, the qualifying rules of that plan
dictate if the product is covered.
Many need prior authorization
Medicare Part C Managed Care
Instructions for data entry into MedAct
Billable QuickCode
Medicare Part C Managed Aetna
American Progressive
AE10
TODAY
Care under Billable = Part B Americhoice NJ (UHC) AM2
Americhoice NY (UHC) AM3
Company Capital District Physicians Health Plan (CDPHP) NDC
CDPHP
Codes should be Added
Enter the Medicare Care Improvement Plus
Centerlight Healthcare
UN23
Center
Part C insurance into CMO HI4
Connecticare CONNECT
the Insurance Data tab Elderplan [If no ID#, use SS#] ELDER
Evercare(United Healthcare Plan Number H3379 or
using the QuickCode. R5342)
EVER [Use Medicare# for ID]

Enter the ID/Policy Gateway Health Plan Gateway

number. Health Insurance Plan of NY (HIP) Only if pt has full

out-of-network coverage feeding sets as well
HI5

Humana HUM
Copy & Paste the Neighborhood NEIGH
eligibility data into the The NY State Catholic Health Plan/Fidelis
Oxford
FIDEL
UN23
customer notes. Pomco PO1
Preferred Care Partners PCPT
SIERRA HEALTH &LIFE INSURANCE COMPANY UN23
Todays Options TODAY
Touchstone TOUCH1
United Healthcare UN23
UHC Plan # H7833 = Non-Med
Wellcare WE3
Medicare Part C Managed Care under
Non-Billable = Non-Med Company
Non-Billable QuickCode
Copy and past the Affinity AFF
Amerigroup AM4
eligibility into the Amerihealth AMERI

customer notes
Archcare Catholic Special Needs Archcare

Atlantis
BCBS (& Anthem Blue Cross)
Bravo - Cigna BRAVO
Conventry
Cuatro / Access Medicare
Empire Healthchoice (BCBS) EM1
Excellus (BCBS) EXC3

Health Assurance Pennsylvania

Geisinger Indemnity
Group Health Incorporated (GHI) GR3

Healthfirst HF
HIP HI5

Horizon Healthcare of NJ (BCBS) NJB3

Independent Health Association INDEP

Kaiser Foundation
Keystone KEY1
Liberty Health Advantage LIB1
Managed Health (Healthfirst) HF
Medica Health Plans
Metroplus Health Plan, Inc. ME5
MMM Healthcare
MVP Healthcare MVP
NY Hotel Trades Council
QCC Insurance Company
Quality Health Plans of NY
VNS Choice VNS

UHC Plan # H7833 = Non-Med

 Medicare Part C managed Care not
on either list = Non-Med Company
QuickCo
Non-Billable
de
Billable QuickCode Affinity AFF
Aetna AE10 Amerigroup AM4
American Progressive TODAY Amerihealth AMERI
Americhoice NJ (UHC) AM2 Archcare Catholic Special
Archcare
Americhoice NY (UHC) AM3 Needs
Capital District Physicians Health Plan Atlantis
(CDPHP) NDC Codes should be CDPHP BCBS (& Anthem Blue Cross)
Added Bravo - Cigna BRAVO
Care Improvement Plus UN23 Conventry
Centerlight Healthcare Center Cuatro / Access Medicare
CMO HI4 Empire Healthchoice (BCBS) EM1
Connecticare CONNECT Excellus (BCBS) EXC3
Elderplan [If no ID#, use SS#] ELDER Health Assurance
Evercare(United Healthcare Plan EVER [Use Pennsylvania
Number H3379 or R5342) Medicare# for ID] Geisinger Indemnity
Gateway Health Plan Gateway Group Health Incorporated
GR3
Health Insurance Plan of NY (HIP) (GHI)
Only if pt has full out-of-network HI5 Healthfirst HF
coverage feeding sets as well HIP HI5
Humana HUM Horizon Healthcare of NJ NJB3
Neighborhood NEIGH (BCBS)
The NY State Catholic Health Independent Health
FIDEL INDEP
Plan/Fidelis Association
Oxford UN23 Kaiser Foundation
Pomco PO1 Keystone KEY1
Preferred Care Partners PCPT Liberty Health Advantage LIB1
SIERRA HEALTH &LIFE INSURANCE Managed Health (Healthfirst) HF
UN23 Medica Health Plans
COMPANY
Todays Options TODAY Metroplus Health Plan, Inc. ME5
Touchstone TOUCH1 MMM Healthcare
United Healthcare UN23 MVP Healthcare MVP
UHC Plan # H7833 = Non- NY Hotel Trades Council
Med QCC Insurance Company
Wellcare WE3 Quality Health Plans of NY
VNS Choice VNS
UHC Plan # H7833 = Non-
Med
In summary

MBS cannot bill for someone in a Part A stay the patient must be entered
into part a company
MBS can bill for someone with traditional Medicare B if the product is
qualified
MBS can bill for someone with an Advantage plan if we are in network with
the plan
MBS cannot bill for someone with an Advantage plan if it is a plan we are
not in network. The patient should be entered into non-med company