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Everything You Need to Know about Medicare Eligibility


Main Points

Medicare has four parts

There are specific requirements to be eligible for Medicare Part A and Part B

Medicare is a public health care program for people aged 65 years or older and for people with very specific disabilities, and for people with end stage renal disease. Medicare has been in place for many years and is widely regarded as a positive program with good administration for elderly people in the United States.

However, this still much confusion about the whole Medicare program, what and who is covered, and what the various parts of Medicare are. We are seeking to write the definitive guide to Medicare eligibility and give a general overview of the Medicare program.

Hopefully, by the end of this blog you will have a good foundation of knowledge for your insurance billing staff or biller, so you can get paid in a timely manner from Medicare. Also, we want you to be better equipped to be paid in a timely manner from the Medicare program.

Medicare has four parts. Surprisingly (or maybe not surprisingly), Medicare is broken up into four distinct parts.

  • Medicare Part A: Hospital Insurance

  • Medicare Part B: Medical Insurance

  • Medicare Part C: Medicare Advantage Plans

  • Medicare Part D: Prescription drug coverage

Medicare Part A is the part of Medicare that helps cover inpatient care in hospitals. This means that if you are provider that works in a hospital providing mental health service, this is the section of Medicare that you would want to bill.

Medicare Part A also covers critical access hospitals and skilled nursing facilities. Part A also covers:

  • Hospice

  • Home health services

  • Inpatient care (i.e. Chemotherapy performed as inpatient

If you do your own eligibility and benefits checks, you will want to ask for the Medicare Part A coverage and not the Medicare Part B coverage.

Medicare Part B covers things not covered by Part A. While that is not the most helpful statement, we will cover what Part B actually covers later. However, Medicare Part B covers things like physician services, medical supplies, lab services, and outpatient mental health services.

Medicare Part B also covers:

  • Clinical research

  • Ambulance services

  • Mental health

  • Certain preventative services

  • Doctor services

  • Outpatient care (i.e. chemotherapy performed as an outpatient service)

Medicare Part C includes all the Medicare advantage plans. These are private plans like HMOs and PPOs that run through Medicare. These plans are required to be at least equivalent to Regular Part A and Part B. Part C plans are managed by private companies contracted with CMS.

Medicare Part C covers:

  • All things covered under Part A except Hospice. Hospice is always covered under Part A

  • May offer vision, hearing, dental, and or other health and wellness programs

Medicare Part C is generally offered by private health insurance companies and employers who have medicare eligible employees.

Medicare Part D covers prescription drugs and each plan has its own formulary meaning there isn't a standard set of coverage details. Please check the patient's benefits and what drugs are covered under their plan.

There are specific requirements to be eligible for Medicare Part A and Part B. People may be eligible for Medicare Part A and Part B if:

  • They are eligible to receive Social Security benefits

  • They are eligible to receive railroad retirement benefits

  • Their spouse receives Social Security or railroad benefits

  • They or their spouse worked long enough in a government job where Medicare taxes were paid

  • They are the dependent parent of a fully insured deceased child

However, a person can also be eligible for Medicare Part A by paying monthly premiums.

A person can be eligible for Medicare Part A before they are 65 if:

  • They have been entitled to Social Security benefits for 24 months

  • They receive a disability pension from the railroad retirement board

  • Receive Social Security benefits due to ALS

  • Have worked long enough in a Medicare-covered government job

  • Are the child or spouse of a worker who has worked long enough under Social Security or in a Medicare-covered government job

Medicare Part B eligibility is available to those 65 or older if

  • They reside in the US as a resident

  • They are entitled to premium free Part A benefits

People that are not eligible for premium free Part A benefits may be eligible for Medicare Part B if:

  • They are a US resident and

  • either citizens or aliens who have been lawfully admitted for permanent residence with 5 years continuous residence in the U.S a the time of filing

Medicare covers a wide range of services for those that are eligible, but also may exclude coverage. Medicare coverage is based on federal and state law and made by the carriers i each state that process claims for Medicare.

Medicare covers many preventative services and you and/or your biller need to be aware of what is or isn't covered. The Affordable Care Act did expand the preventative services that are covered under Medicare and that list can be found on the CMS website.

Here is a cursory list of the services that are covered under the medicare program:

  • Annual wellness visits

  • Bone mass measurements

  • Cardiovascular disease screening

  • Colorectal cancer screening

  • Tobacco prevention counseling

  • Diabetes screening tests

  • Glaucoma screening

  • Screening for depression

Medicare Part A, B, C, and D can be confusing to understand and we hope that this blog serves as a primer to the program. Before billing Medicare or Medicaid you will want to make sure that you are an in-network provider.

Billing Medicare out of network is a very challenging prospect which we will deal with in future posts, but generally your claims will have a hard time processing unless you are a participating provider.

If you are a participating provider you can access eligibility and benefit information via online portals or your billing service, and it will be crucial to know the eligibility and benefits of all your medicare patients before rendering services.

You will want to follow your contract and the Medicare guidelines closely so that you are staying compliant will all of Medicare's rules and regulations.

If you still find Medicare difficult to navigate or confusing our staff are willing and available to help you sort through your questions. Give us a call or contact us through the website and we will be in touch very shortly!

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