HELP--payment sources...the difference in all...

CT Pixie, BSN, RN · Jul 3, 2008

I presently work for an insurance company and I handle the Medicare supplemental policy so I can help a bit with your questions.

Medicare is Federally Funded . Here's a great link thats geared toward the medicare recepients so it's not too techincal in terms etc http://www.medicare.gov/coverage/Home.asp

Medicare Part A is medical coverage that covers your INpatient hospitalizations. This includes hospitals and rehab/SNF inpatient charges.

Medicare Part B is for your outpatient charges (labs, x-rays, dr visits, PT/OT things of that nature) Medicare Part B pays 80% of the approved amount of the charge, the other 20% is coinsurance that the pt is responsible for. There are quite a few charges that aren't covered by medicare such as routine yearly physicals, certain DME, routine labs, those types of things. And part B does not cover medications.

Some people have only Medicare Part A, others have both.

Medicaid is a State funded insurance for lower income people. (aka State Insurance, Title 19 etc) This type of insurance covers all medical/dental/vision charges.

There are medicare supplemental policies that some people have that they get through retirement plans or personal individual policies. This type of insurance generally picks up the co-insurance, in patient deductibles that medicare doesn't cover. And pay after medicare makes their payment. Many of these policies follow medicare's lead. If medicare denies the charge chances are the supplemental policy will also (there are some that do pay denied charges, but those policies tend to be a bit pricey)

txredheadnurse, BSN, RN · Jul 3, 2008

Medicare Part D is medication coverage. A patient can also have this particular type of Medicare coverage even if they have Medicaid only for their primary health insurance. There are several providers of Medicare Part D coverage and each one varies as to co pays, which drugs are covered, yada yada yada lol.

The other thing to remember is Medicaid (which is primarily State funded) is also the last payor source. In other words if a patient has both Medicare and Medicaid for example, then Medicaid is treated as a secondary insurance.

Yep, it can be a mind boggling thing dealing with these government funded health plans. I swear I have a bald patch on my head from pulling out my hair in frustration trying to figure out which plan covers what, when and how much.

CT Pixie, BSN, RN · Jul 3, 2008

Yup, Medicaid always past last.

Just another thing to add to all the confusion. If a Medicare patient is aactively employeed and has an insurance policy through work, the policy through work is primary, medicare is secondary and if they have a medicare supplemental policy or Medicaid they would be tertiary.

Some general info (for 2008) this is info I know like the back of my hand LOL. This is my work day in and day out!

Medicare Part A:

Blood: Pt pays all costs for the 1st 3 pints of blood they get as an inpatient, then 20% of the medicare approved amount for additional pints of blood (unless the pt or someone else donates to relace whats used)

Home Health Care

Patient pays $0 for home health services

Patient pays 20% of the medicare approved amounts for DME

Inpatient Hospital Stay

Patient pays $1024 inpatient deductible and no coinsurance for days 1-60 inpatient

patient pays $256 per day for days 61-90

patient pays $512 per lifetime reserve days after day 90. (LIFETIME RESERVE DAYS ARE UP TO 60)

Skilled nursing facility stay

patient pays $0 for the 1st 20 days

patient pays $128 for days 21-100

patient pays all cost for each day after day 100

Medicare Part B

Pt is responsible for the first $135 of medicare approved charges

Pt is responsible for denied charges (careful here, there are times that medicare does deny a claim and makes no payment and holds the pt responsible for said charges, there are other times where medicare will deny a claim, make no payment and deems the pt cannot be charged for that charge. You have to check the denial code medicare gives (anything CO with a number after it is a charge that was denied for whatever reason but the provider of service cannot bill the pt. If pt is billed and the provider demands payment, its considered Medicare fraud. Anything with a denial code of PR and a number after it is patient responsibility)

If you have any specific questions feel free to PM me. Like I said I have 15 years of Medicare/Medicaid/Supplemental Insurance experience, so I should be able to help, and if I can't I'm sure I could find a website that can help.I've been doing this for 15 years and I am still baffeled by some of the rules and regulations, they seem to change them at the blink of an eye. :banghead:

mpccrn, BSN, RN · Jul 4, 2008

does that mean we should all just quit and get medicaid?? they cover all medical, dental and vision charges.....that's better than i have and i work full time in a hospital! :angryfire

Nascar nurse, ASN, RN · Jul 4, 2008

I'll see if I can help a little related to nursing homes and MDS's

Medicare A/federally ran progam - (Generally those over 65 or declared disabled)

Requires a 3day (actually 3 midnight) stays in a hospital within the past 30 days

Requires a Dr's certification that the resident requires daily skilled care

Requies that the resident have medicare A coverage (can not "assume" that everyone over 65 has this as I have ran across a few over the years that never paid taxes or whatnot and did not have medicare A benefits). Your business office manager should be able to pull up a "common working file". This is a medicare benefit computer site that will validate that the resident does/does not have medicare A and B benefits. It will also tell how many benefit days are available to the resident.

If a resident has full benefits, they have 100 days available to them. Medicare A pays 100% of all costs for the first 20 days and 80% from day 21-100. The resident pays the 20% "co-payment" from a secondary insurance, private funds or medicaid.

Residents are not guarenteed 100 days. They have to continue to meet daily skilled nursing care or therapy services at least 5 days/week. Unfortunately, this is not explained well to the resident prior to admission to us and then they get very upset with us when we explain that there medicare service is being terminated prior to day 100. (They have certain appeal rights available if it turns into a big deal)

From an MDS stand point, you will need to understand that the facility is being reimbursed for all medicare A care based on the residents RUG score. This is why it is extremely important to understand this. That RUG score determines what the facility will get for room/board, all medications, therapy services, labs, X-rays, etc. If an MDS coordinator is not coding correctly, the facility can lose thousands of $'s quickly.

Medicare B - This is a medicare supplemental policy(they pay extra for this). They have to have part A to have part B, BUT just because they have part A does mean they have part B. Again you have to go back to the common working file to verify benefits.

Part B in a nursing home is only used to cover therapy costs only after prt A benefits have been exhausted. Example: A resident comes into facility following acute CVA - resident uses 100 medicare days, but continues to make progress and could benefit from additional therapy. Medicare B will cover this, but there has been a "cap" on the allow reimbursement - not sure if this have been changed yet.

Medicaid/State run program- This is for "poor people". Those folks that have very very little or nothing to cover their costs. Like someone else said - it is always the last form of payment coverage. This gets used when there is nothing else to use! From an MDS standpoint, I can't help you. From reading these forums... every state seems to run different.

Well I either helped you or confused you to death. Good luck

nursewiggins78 · Jul 4, 2008

:loveya:hey!!! I see a bright light at the end of a very long tunnel!!!!! hahahaha. thanks yall for all the feedback, that helps soooo much!

kristi