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Medicare Handbook, 2018 Edition

By Alfred J. Chiplin, Jr., Judith A. Stein
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To provide effective service in helping people understand how they are going to be affected by health care reform and how to obtain coverage, pursue an appeal, or plan for long-term care or retirement, you need the most current information from a source you can trust - Medicare Handbook.

This is the indispensable resource for clarifying Medicare's confusing rules and regulations. Prepared by an outstanding team of experts from the Center for Medicare Advocacy, it addresses 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; coinsurance, premiums, penalties; coverage criteria for each of the programs; problem areas of concern for the advocate; grievance and appeals procedures.

The 2018 Edition of Medicare Handbook offers expert guidance on:

  • Medicare Enrollment and Eligibility
  • Medicare Coverage in all Care-Settings
  • Medicare Coverage for People with Chronic Conditions
  • Medicare Home Health Coverage and Access to Care
  • Prescription Drug Coverage        
  • Medicare Advantage Plans
  • Medicare Appeals
  • Health Care Reform
  • And more!

In addition, Medicare Handbook will help resolve the kinds of questions that arise on a regular basis, such as:

  • How do I appeal a denial of services?
  • What steps do I need to take in order to receive Medicare covered home health care?
  • What are the elements of Medicare's appeal process for the denial of coverage of an item, service, or procedure?
  • Does my state have to help me enroll in Medicare so that I can get assistance through a Medicare Savings Program?
  • When should I sign up for a Medigap plan?
  • If I am enrolled in Medicare, do I have to buy health insurance in the insurance marketplace created by the Affordable Care Act?
  • Is it true that I have to show medical improvement in order to get Medicare for my nursing and therapy services?
  • And more!

The 2018 Medicare Handbook is the indispensable resource that provides:

  • Extensive discussion and examples of how Medicare rules apply in the real world
  • Case citations, checklists, worksheets, and other practice tools to help in obtaining coverage for clients, while minimizing research and drafting time
  • Practice pointers and cautionary notes regarding coverage and eligibility questions when advocacy problems arise, and those areas in which coverage has often been reduced or denied
  • And more!

Note: Online subscriptions are for three-month periods.

Previous Edition: Medicare Handbook, 2017 Edition ISBN 9781454871170

Product Line Wolters Kluwer Legal & Regulatory U.S.
SKU 000000000010048356
Last Updated 01/23/2018
Update Frequency Updated annually
Product Line Wolters Kluwer Legal & Regulatory U.S.
ISBN 9781454884224
SKU 10045179-0002
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
    • Conditional Payment and Third-Party Recovery
    • MSP Workers' Compensation Recovery
    • MSP Collection Procedures
    • Mandatory Reporting by Insurers
    • Beneficiary Rights to Seek Waiver or Appeal the MSP Recovery Claim
  • 10. Dual Eligibility: Issues for Medicare Beneficiaries Also Eligible for Medicaid
    • Profile of the Dually Eligible
    • Summary of Medicaid Eligibility and Medicaid Benefits
    • Universe of Dual Eligibility
    • Enrollment Issues for Medicare Savings Programs Population
    • Access Issues for the Dually Eligible Population
    • Managed Care Issues for Dually Eligible Individuals
    • Programs of All-Inclusive Care for the Elderly
  • 11. Prescription Drug Coverage
    • Eligibility for Part D Coverage
    • Choice of Drug Plans
    • The Part D Drug Benefit
    • Enrolling in a Part D Plan
    • Premium and Cost-Sharing Subsidies for Part D Prescription Drugs for Low-Income Individuals
    • Dual Eligibles
    • State Pharmaceutical Assistance Programs (SPAPs)
    • Grievance, Appeals, and Exceptions Processes