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Medicare Explained, 2021 Edition by Wolters Kluwer Editorial Staff

Medicare Explained, 2021 Edition

By Wolters Kluwer Editorial Staff


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Medicare Explained has been prepared for Medicare beneficiaries and others who need a relatively thorough explanation of the Medicare program with particular emphasis on services covered in institutional settings and services provided by physicians and suppliers.

Published annually, Medicare Explained includes changes made during 2020 by law and regulation amendments and updates to program manuals issued by the Centers for Medicare and Medicaid Services (CMS).

Medicare Explained includes:

  • Analysis of legislative, regulatory, and agency guidance issuance on available benefits
  • Medicare coverage and exclusions
  • The administration of the Medicare program
  • Medicare payment rules under Parts A, B, C, and D
  • Details on the process for submitting beneficiary claims as well as the appeals process

The 2021 Edition has been updated to include:

  • Impacts of the COVID-19 pandemic on Medicare coverage and reimbursement
  • Discussion of changes to Medicare eligibility made by recent legislation
  • Discussion of quality of care initiatives

Previous Edition: Medicare Explained, 2020 Edition, ISBN: 9781543821185

Pages 424
Last Updated 03/26/2021
Update Frequency Annually
Product Line Wolters Kluwer Legal & Regulatory U.S.
ISBN 9781543832471
SKU 10032106-0012
Table of Contents

1. Introduction

2. Medicare Part A—Hospital Insurance
Eligibility and Enrollment
Entitlement to Part A Hospital Insurance Benefits
Voluntary Enrollment in the Hospital Insurance Program
Disability Beneficiaries
End-Stage Renal Disease Beneficiaries
Government Employees
Inpatient Hospital Services
Inpatient Hospital Services: Coverage in General
Drugs and Biologicals
Supplies, Appliances, and Equipment
Other Diagnostic and Therapeutic Items and Services
Services of Interns, Residents-in-Training, and Teaching Physicians
Nursing and Medical Social Services
Inpatient Rehabilitation Facilities
Inpatient Benefit Period and "Spell of Illness"
Inpatient Lifetime Limitation
Inpatient Hospital Deductible and Coinsurance
Psychiatric Hospital Restrictions
Emergency Services Provided in Nonparticipating Hospitals
Religious Nonmedical Health Care Institutions
"Hospital" Defined—Qualified Hospitals
Nursing Home Services
Introduction to Covered Nursing Home Services
Nursing Care
Physical and Occupational Therapy and Speech-Language Pathology Services
Medical Social Services
Drugs and Biologicals
Supplies, Appliances, and Equipment
Interns and Residents-in-Training
Whole Blood and Packed Red Blood Cells
Other Diagnostic and Therapeutic Items or Services
SNF Services Provided by Religious Nonmedical Health Care Institutions
SNF "Ancillary" Services Payable Under Part B
Skilled Nursing Facility Coinsurance
Prior Hospitalization and Transfer Requirements
Rights of SNF Residents
"Skilled Nursing Facility"—Conditions of Participation
Home Health Services
Home Health Services: Qualifying Conditions for Coverage
Skilled Nursing Care
Physical and Occupational Therapy and Speech-Language Pathology Services
Home Health Medical Social Services
Home Health Aides
Medical Supplies and Durable Medical Equipment
Interns and Residents-in-Training
Outpatient Services
Physician Certification and Recertification of Home Health Services
Home Health Plan of Care Requirement
Patient Confined to Home
Home Health Visits
Specific Exclusions from Home Health Coverage
"Home Health Agency Defined"—Qualified Home Health Agencies
Hospice Care
Hospice Care: Coverage in General
Election of Hospice Care
Certification and Care Requirements
Discharge from Hospice Care
Deductibles and Coinsurance
Hospice Program Requirements

3. Medicare Part B—Supplemental Medical Insurance
Eligibility and Enrollment
Eligibility for Medicare Part B Benefits
Enrollment in Medicare Part B
Enrollment Periods for Medicare Part B
Part B Coverage Period
Termination of Medicare Part B Coverage
Medicare Part B Premiums
Part B Benefits: In General
Deductible and Coinsurance
Medical and Other Health Services
Physicians' Services
Services and Supplies Furnished Incident to Physicians' Services
Outpatient Hospital Services
Diagnostic X-Ray, Laboratory, and Other Diagnostic Tests
X-Ray, Radium, and Radioactive Isotope Therapy
Ambulance Services
Durable Medical Equipment
Prosthetic Devices and Prosthetics/Orthotics
Surgical Dressings, Splints, and Casts
Inpatient Ancillary Services
Drugs and Biologicals
Other Health Care Practitioners
Preventive Services
Therapeutic Shoes
Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
Rural Health Clinics and Federally Qualified Health Centers
Home Health Services
Comprehensive Outpatient Rehabilitation Facility Services
Ambulatory Surgical Services
Mental Health Services
Telehealth Services
End-Stage Renal Disease Services
Home Infusion Therapy
Outpatient Rehabilitation Programs
Opioid Use Disorder Treatment Services
National and Local Coverage Decisions

4. Medicare Part C—Medicare Advantage
Overview of Medicare Part C
Eligibility, Election, Enrollment, and Disenrollment
Benefits and Beneficiary Protections
Beneficiary Grievances, Organizational Determinations, and Appeals
Contracts with Medicare Advantage Organizations
Medicare Advantage Bids and Benchmarks
Beneficiary Premiums and Cost-Sharing
Payments to Medicare Advantage Organizations
Communication Requirements
Quality Improvement Programs
Relationships with Providers
Intermediate Sanctions and Civil Money Penalties

5. Medicare Part D—Prescription Drug Benefit
Overview of Medicare Part D
Eligibility and Enrollment
Payment of Part D Premiums
Part D Deductible and Coinsurance Requirements
Premium and Cost-Sharing Subsidies for Low-Income Individuals
Benefits and Beneficiary Protections
Grievances, Coverage Determinations, Redeterminations, and Reconsiderations
Reopenings, ALJ Hearings, Medicare Appeals Council Review, and Judicial Review
Cost Control and Quality Improvement Requirements
Payments to Sponsors of Retiree Prescription Drug Plans
Communication Requirements

6. Exclusions from Coverage
Exclusions Under Part A and Part B
Services Not Reasonable and Necessary
No Legal Obligation to Pay
Services Paid for by Governmental Entity
Services Outside the United States
Services Resulting from War
Personal Comfort Items
Eye, Ear, and Foot Care
Custodial Care
Cosmetic Surgery
Charges by Immediate Relatives and Household Members
Dental Services
Services Not Provided In-House
Medicare as Secondary Payer
Services of Excluded Individuals and Entities
Certain Services of Surgery Assistants

7. Administrative Provisions
HHS and CMS Organizational Structure
Role of the State and Local Agencies
Role of Medicare Administrative Contractors
Quality Improvement Organizations
Recovery Audit Contractors
Privacy of Health Data
Electronic Health Records
Fraud and Abuse Penalties
Provider Participation Agreements
Role of Medicaid
“Medigap” Insurance

8. Payment Rules
Inpatient Hospital Services
Long-Term Care Hospitals
Hospital Outpatient Services
Ambulatory Surgical Centers
Hospice Reimbursement
Home Health Agencies
Skilled Nursing Facilities
Inpatient Rehabilitation Facilities
Psychiatric Hospitals and Units
End-Stage Renal Disease
Rural Health Facilities
Federally Qualified Health Centers
Accountable Care Organizations
Physician Fee Schedule
Nonphysician Practitioners
Actual Charge Restrictions
Participation Program for Physicians and Suppliers
Private Non-Medicare Contracts with Health Care Practitioners
Clinical Diagnostic Laboratory Tests
Ambulance Fee Schedule
Durable Medical Equipment, Prosthetics, Orthotics, and Other Supplies
Payment for Drugs and Biologicals
Home Infusion Therapy
Opioid Use Disorder Treatment Services

9. Claims, Payments, and Appeals
Claims and Payments
Certification and Recertification of Medical Necessity
Guarantee of Payment to Hospitals
Payments on Behalf of a Deceased Beneficiary
Overpayments and Underpayments
Limitation of Liability
Medicare Entitlement and Enrollment Appeals
Medicare Part A and B Claims Appeals
Expedited Appeals of Provider Service Terminations
NCD and LCD Appeals
Recovery Audit Contractor, Cost Report, Status, Exclusion, and Suspension Appeals