An explanation of Medicare
This article, provided by Palmetto GBA Railroad Medicare, outlines the various “parts” of Medicare and explains which types of services are covered under each.
What Is Part A?
Part A includes inpatient hospital, skilled nursing facility (or SNF), nursing home, hospice and home health services care. It also includes long-term care acute care (LTAC). Part A Medicare claims are processed by the local Medicare administrative contractor for your state. Railroad Medicare processes your Part B claims, while your local Medicare administrative contractor handles your Part A claims.
What is Part B?
Part B services include medically necessary services and preventive services provided by doctors/physicians/surgeons and practitioners (such as nurse practitioners, physician assistants, qualified clinical psychologists, clinical social workers, certified midwifes and certified registered nurse anesthetists). Other providers and suppliers in the Part B program include chiropractors, podiatrists, ambulance services, and laboratories. Claims for these types of services are processed by Railroad Medicare/Palmetto GBA in Augusta, Ga.
What is Part C?
Part C is Medicare Advantage plans, such as Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). These plans are offered by private companies that contract with Medicare to cover your Part A and B benefits. Other Medicare Advantage Plans include:
* Private Fee-For-Service (PFFS) – PFFS are offered by private insurance companies and let you receive health care from any doctor or other health care provider or hospital in the PFFS plan. Prescription drug coverage may also be offered by a PFFS plan.
* Special Needs Plans (SNP) – SNP limits membership to patients with specific illnesses and customizes their benefits to serve the needs of their members. For more information on SNP, please visit www.Medicare.gov.
* Medical Savings Accounts (MSA) – MSAs have a high deductible and in many cases only pays for covered Part A and B services once you have reached your deductible. The plan deposits funds (which typically are less than the deductible) into a designated account to pay for your health care services during the year.
What is Part D?
Part D is coverage for prescription drugs, and like Part C, the program is administered by private insurance companies. Part D plans have their own list of covered medicines, with a tiered pricing system. This means that some drugs, such as generics, may be in the lowest tier and have the lowest copayment. Drugs in the highest tiers would have the highest copayment. If you sign up for a Part D plan when you are first eligible you avoid paying a penalty. A penalty would be assessed if you don’t join when you were first eligible and you don’t have other drug coverage or don’t receive “Extra Help”. Beneficiaries with limited income and assets may qualify for “Extra Help” to help pay for prescription drugs. This program is administered through the Social Security program and Medicare. For more information, please visit www.SSA.gov/prescriptionhelp/.
DMEPOS stands for coverage of Durable Medical Equipment, Prosthesis and Prosthetic Devices, Orthotics and Supplies. DMEPOS would include items such as walkers, wheelchairs, diabetic shoes, and hospital beds, to name a few. Claims for these and many more products are filed to Durable Medical Equipment (DME) Medicare Administrative Contractors. Railroad Medicare doesn’t handle DME claims.
An example of how the letters work together
An example of how one procedure is covered by multiple parts of Medicare is for individuals receiving a cardiac pacemaker. The actual pacemaker (which is a DMEPOS — prosthetic device) is billed to your local DME Medicare administrative contractor. Hospital charges fall under your Part A benefit, and the physician’s fee, including post-surgical care, is billed to Part B.
If you have questions about your Railroad Medicare (Part B) claims, call Palmetto’s beneficiary contact center at (800) 833-4455, Monday through Friday, 8:30 a.m. until 7 p.m. ET. For the hearing impaired, call TTY/TDD at (877) 566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available. You can also visit Palmetto’s website at www.PalmettoGBA.com/rr/me.
For more information about the general Medicare program, or specifically about Part C or Part D, you can contact your local state health insurance counseling and assistance program, or SHIP. SHIP is a free program offered by all 50 states, as well as Guam, Puerto Rico and the Virgin Islands. SHIP counselors can help you learn more about the Medicare program and Medicare supplemental plans, as well as other long-term insurance options. To find a SHIP office for your state, visit http://www.medicare.gov/contacts/organization-search-criteria.aspx and enter “SHIP — State Health Insurance Assistance Program” and select your state. Or you may call (800) MEDICARE for more information.