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Medicare Part B
Outpatient or supplementary medical insurance.
Covers:
- physicians
- nurse practitioners
- social workers
- psychologists
- therapists
- laboratory tests
- durable medical equipment
- home visits (traditional fee-for-service) [2]
Does not cover:
- health maintenance physical examinations
- dental care
- hearing aids
- eye glasses
- foot care
- orthopedic shoes
- cosmetic surgery
- care in foreign countries
- long-term care
- round the clock home care
- home maker services
- help with activities of daily living
Eligibility:
- entitlement to Medicare Part A or citizen or permanent resident of USA
- must enroll & pay premiums ($96-$354/month in 2010) depending upon income
- generally premiums deducted from social security check
A deductable ($166/year 2016) is applied to reimbursement for outpatient services. After deductable is paid, Medicare part B covers 80% of office visits & 100% of diagnostic labs.
Durable equipment including pressure-relieving mattresses are covered when indicated
Medicare policy indicates that home health agencies should teach patients & their families to assume responsibilities for their own care, rather than rely on the home health agency for provision of all aspects of care
Part B is financed in 2 ways.
1) monthly premiums ($105-390/month in 2016) deducted from Social Security benefits of enrollees
- premiums cover 25% of average expenditures for aged beneficiaries
2) contributions from the general revenue of the US Treasury
Physicians must choose among 3 options in relation to the Medicare fee-for-service: participant, a nonparticipant, or a private contractor.
Participants submit a claim to the Part B carrier for each Medicare-covered service, accepts Medicare fee for the service (80% of its preestablished amount) & bills the patient of patient's other insurance for no more than 20%
Nonparticipants can bill patients directly for up to 15% more than 95% of Medicare allowed amounts; the patient pays the physician, then submits a claim to Medicare for partial reimbursement (80% of 95% of the allowed amount); Medicare reimburses the patient, not the provider
Physicians may opt out of Medicare entirely, but must do so for all of their patients (concierge practice); they enter into private contracts with their patients
General
Medicare
References
- Smith, R. Jewish Home for the Aging, Reseda CA, 2001, unpublished
- Geriatrics Review Syllabus, American Geriatrics Society,
5th edition, 2002-2004
- Geriatric Review Syllabus, 7th edition
Parada JT et al (eds)
American Geriatrics Society, 2010
- Geriatric Review Syllabus, 8th edition (GRS8)
Durso SC and Sullivan GN (eds)
American Geriatrics Society, 2013
- Geriatric Review Syllabus, 9th edition (GRS9)
Medinal-Walpole A, Pacala JT, Porter JF (eds)
American Geriatrics Society, 2016
- Geriatric Review Syllabus, 11th edition (GRS11)
Harper GM, Lyons WL, Potter JF (eds)
American Geriatrics Society, 2022
- Home Health Agency Center:
Centers for Medicare and Medicaid Services
United States Department of Health and Human Services
http://www.cms.hhs.gov/center/hha.asp