Medicare Handbook, 2011 Edition

Medicare Handbook, 2011 Edition

by Judith A. Stein, Jr. Chiplin
     
 

ISBN-10: 0735591490

ISBN-13: 9780735591493

Pub. Date: 12/08/2010

Publisher: Wolters Kluwer Law & Business

The 2010 Medicare Handbook is the indispensable resource you need to clearly understand - and be able to advise on - Medicare's confusing rules and regulations. It has been prepared by an outstanding team of experts from the Center for Medicare Advocacy, Inc., a private, non-profit organization devoted to helping elders and people with disabilities obtain

Overview

The 2010 Medicare Handbook is the indispensable resource you need to clearly understand - and be able to advise on - Medicare's confusing rules and regulations. It has been prepared by an outstanding team of experts from the Center for Medicare Advocacy, Inc., a private, non-profit organization devoted to helping elders and people with disabilities obtain necessary healthcare. These experienced attorneys and healthcare professionals address - from the beneficiary's perspective - issues you need to master to provide effective planning advice or advocacy services, including:

  • Medicare eligibility rules and enrollment requirements
  • Medicare covered services, deductibles, and co-payments
  • Co-insurance, premiums, penalties
  • Coverage criteria for each of the programs
  • Problem areas of concern for the advocate
  • Grievance and appeals procedures

For each topic, you'll find an extensive selection of case citations, checklists, worksheets, and other practice tools designed to assist in obtaining coverage for clients, while minimizing research and drafting time.

The 2010 Medicare Handbook has been updated to include coverage of:

  • Re-bidding under the competitive bidding for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as re-introduced in the fall of 2009
  • Understanding the strengths and weaknesses of the variety of SNPs available under the Medicare Advantage program (Medicare Part C)
  • Continued efforts on educating beneficiaries about their rights, particularly with respect to moving from one care setting to another
  • Developments in the Medicare Hospice Care Benefit, including in-the-home hospice care as opposed to hospice in a skilled nursing facility
  • Ongoing problems with the implementation of the Medicare Part D prescription drug benefit, including providing good information about how to appeal the denial of coverage of drugs not on a plan's formulary

Product Details

ISBN-13:
9780735591493
Publisher:
Wolters Kluwer Law & Business
Publication date:
12/08/2010
Pages:
922
Product dimensions:
7.00(w) x 10.00(h) x 1.80(d)

Table of Contents


• 1. An Introduction to Medicare Coverage and Appeals


• History and Overview
• Financing
• Administration
• Enrollment and Eligibility
• Coverage
• Medicare Savings Programs
• The Medicare Appeals Process


• 2. Hospital Coverage


• Eligibility for Medicare Hospital Insurance (Part A)
• Application or Enrollment for Medicare Part A
• Scope of Benefits - Inpatient Hospital Coverage Benefit Periods
• Medicare-Covered Services
• Coverage Criteria Explained
• Limitations on Payment for Services
• The Medical Necessity Standard for Inpatient Hospital Stays
• Hospital Payment
• Utilization Review and Quality of Services
• Appealing Coverage Denials
• Denial and Appeal Process
• How to Develop a Winning Appeal


• 3. Skilled Nursing Facility Coverage


• Coverage
• Qualifying Criteria
• Identifying Coverable Cases
• SNF Prospective Payment System and Resource Utilization Groups
• Problem Areas of Concern for the Advocate
• Pre-Appeals Advocacy
• Appeals


• 4. Home Health Coverage


• Coverage
• Requirements for Coverage
• Chronic, Stable, and Maintenance-Level Patients
• Prospective Payment System (PPS) for Home Health Services
• Claims Submission, Determination, and Appeal
• The Role of Advocacy
• How to Develop a Winning Appeal


• 5. Hospice Coverage


• Eligibility
• Election of the Hospice Benefit
• Who May Make an Election for Hospice Care
• Hospice Admission
• Patient Rights
• Hospice Revocation
• Hospice Discharge
• Changing Hospice Providers
• Hospice Services
• Medicare Rules for Hospice Inpatient Care
• Medicare Hospice Inpatient Cap
• Hospice Care for Residents of Facilities
• Deductibles and Coinsurance for Non-Hospice Care
• The Appeals Process
• The Medicare Prescription Drug, Improvement, and Modernization Act of 2003


• 6. Medicare Part B: Supplementary Medical Insurance Benefits for the Aged and Disabled


• Enrollment and Payment Requirements
• Covered Medical and Other Health Care Services
• Medicare Assignment Program
• Filing Medicare Part B Claims
• Information About Coverage
• Appeals
• Appointments of Representatives and Attorneys' Fees


• 7. Medicare Advantage: Coordinated Care Plans, Private Fee-for-Service, and Other Delivery of Services Options


• Advantages and Disadvantages of Medicare Advantage Options
• Guidelines for Considering Medicare Advantage Options
• Medicare Advantage
• Medicare Advantage Quality Improvement Program


• 8. Medigap Services


• Medicare Certification of Policies
• Standardized Plans
• High Deductible Plans
• Medicare SELECT
• Legislated Policy Changes
• Consumer Protections
• Prohibition Against Sale of Duplicate Policies
• Required Ratio of Aggregate Benefits to Aggregate Premiums
• Coverage of Preexisting Conditions
• Dissemination of Information About Medigap Policy Benefits
• Adding Cost-Sharing to Medigap Policies


• 9. Medicare's Relationship with Private Insurance


• Employer Group Health Plans
• Calculation of Medicare Secondary Payment Amount in EGHP Cases
• Enforcement of EGHP Claims
• Coordination of COBRA Rights and Medicare
• MSP Rules Applicable to Medicare Advantage Plans
• Condi

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