Pub. Date:
Wolters Kluwer Law & Business
Medicare Handbook, 2011 Edition

Medicare Handbook, 2011 Edition

by Judith A. Stein, Jr. Chiplin


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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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