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Medicare and Medicaid

Yale-New Haven Hospital Saint Raphael Campus accepts both Medicare and Medicaid insurance. When you receive healthcare services at Yale-New Haven Hospital Saint Raphael Campus, you will be asked to provide positive identification and your Medicare and/or Medicaid identification card. Whenever possible, please bring these documents with you when you come to the hospital.

Patients will be asked to sign a "Consent to Hospital Admission and Medical Treatment Form." Medicare patients should also expect to answer questions for the Medicare Secondary Payer (MSP) provisions. These questions are required by Medicare. If you are admitted as an inpatient, you will be asked to sign a form entitled, "An Important Message From Medicare About Your Rights." This notice provides information on your discharge appeal rights. Click here for more information about Medicare hospital benefits.

Inpatient vs. Outpatient Status

I spent the night in the hospital - so why am I an "outpatient"?

An overnight stay at the hospital doesn't guarantee inpatient status for older adults on Medicare. Medicare requires your doctor to order an inpatient admission and the hospital to review and document the medical necessity. Only a qualified admission entitles you to hospital coverage benefits under Medicare Plan A (Hospital Insurance).

Odd as that sounds, Medicare Plan A only covers inpatient hospital services. If you go to the hospital  and stay the night "for observation" without a doctor "admitting" you, your Medicare Plan B (Medical Insurance) - which covers outpatient services (like X-rays, lab tests) and physician services -  kicks in. That can mean deductibles and copayments for every treatment you receive.

Confused? Here's how it works:

Scenario 1
You go to the Emergency Department (ED) with shortness of breath. Based on your anticipated medical needs, the physician writes an inpatient admission order, which is subject to review. If medical necessity is documented, you're now covered for both emergency services and inpatient services under Medicare Plan A, with a one-time deductible for hospital services for the first 60 days you're in the hospital.

Scenario 2
You go to the ED with chest pains and the physician determines you need overnight observation. You're considered an outpatient. Medicare Part A pays nothing. Part B covers ED and observation services - but you'll have separate copayments for each outpatient service in addition to paying 20% of the Medicare-approved amount for doctor services. In some cases, your total copayment for outpatient services may exceed the inpatient deductible.

For overnight hospital stays, always ask your doctor if you have been admitted as an inpatient. Medicare coverage for follow-up care in a skilled nursing facility requires that you have a qualified inpatient admission; outpatient care under observation will not qualify you for Medicare Part A payment in a nursing home.

To learn more call 800.MEDICARE (800.633.4227).

Definitions - Medicare & Medicaid

Advance Beneficiary Notice

A written notice given to Medicare beneficiaries by providers (physicians, outpatient service providers, and others paid under Medicare Part B) to inform the beneficiary that Medicare is not likely to cover a specific medical item or service. The notice must be provided in advance of receiving the item or service in order to give the beneficiary time to consider other options.

Coordination of Benefit (COB) Rules

Regulations which determine which insurance is to be billed first (primary) for services when the patient is covered by more than one insurance. These rules are established by state and federal government guidelines.

Medicaid

A jointly-funded, Federal-State health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income maintenance payments. It is "need-based" not "age-based."

Medicare

A federal health benefit program for people over 65, certain disabled individuals under 65 and people of any age who have permanent kidney failure. The program covers 35 million Americans - or about 14% of the population.

Medicare Benefits Notice

A notice you get after your doctor files a claim for Part A (hospital) services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You may also get an Explanation of Medicare Benefits (EOMB) for Part B (medical) services or a Medicare Summary Notice (MSN).

Medicare Coverage

Includes Hospital Insurance (Part A) and Medical Insurance (Part B). Also see: Medicare Part C and Part D.

Medicare Part A (Hospital Insurance)

Hospital insurance that pays for in-patient hospital stays, some care in a skilled nursing facility, hospice care and some home health care. Beneficiaries are responsible for deductibles and co-payments.

Medicare Part B (Medical Insurance)

The part of Medicare that covers doctors' services and outpatient hospital care. It also covers other medical services that Part A does not cover, like medical supplies, physical and occupational therapy. Beneficiaries are responsible for monthly premiums, co-payments, deductibles and balance billing.

Medicare Part C (Medicare Advantage Plans - Similar to an HMO)

This gives patients a choice to receive their Medicare benefits through private health insurance plans. Out of pocket expenses vary by plan. Plans may include coverage for items such as dental or vision care not included as benefits in the traditional Medicare Part A . In exchange for these benefits, enrollees may be limited to "in-network" providers they can use without paying anything extra. Going outside the network may require permission, extra fees or may not be covered.

Medicare Part D (Prescription Coverage)

For this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan. These plans are approved and regulated by Medicare but designed and administered by private health insurers. Unlike Medicare Part A and B, Part D coverage isn't standardized. Plans choose which drugs they will cover and at what level, if at all. Part D excludes certain drugs from coverage, but for beneficiaries eligible for both Medicaid and Medicare, Medicaid may pay for drugs not covered by Part D of Medicare.

Medicare Secondary Payer

Required by law, the Medicare Secondary Payer (MSP) provisions protect the Medicare Trust Fund by ensuring Medicare doesn't pay for services that other health insurance has primary responsibility for paying. A provider (doctor, hospital, health care center) is obligated to determine who is the primary payer when delivering treatment/services to a Medicare patient in order to ensure appropriate billing. Click here for more on "Secondary Payer."

Medicare Supplement Policy (Med Supp)

For an additional premium, the insurance may pay a policyholder's Medicare co-insurance, deductible and co-payments for Medicare Part A and B and may provide additional supplemental benefits according to the policy selected.

Advance Beneficiary Notice

An Advance Beneficiary Notice (ABN) is a notice to beneficiaries in traditional Medicare explaining that Medicare is not likely to cover a specific service. The ABN may be given by physicians or providers of outpatient services. The ABN must be delivered to beneficiaries in advance of receiving the item or service to allow the beneficiary time to consider if he or she wants the service. The beneficiary will have the opportunity to ask questions. The ABN will explain the reason payment by Medicare isn't expected and outline the estimated cost to the beneficiary if he/she decides to receive the item/service. Common reasons Medicare will deny payment include:

  • Medicare doesn't consider the item or service medically necessary
  • The item or service has been provided in excess of frequency limits
  • The item or service is experimental.

In order for the ABN to be valid, it must be fully completed. The beneficiary then must indicate his/her choice. The options include:

  1. The beneficiary may choose to sign the ABN, agreeing to pay for the service. The beneficiary requests that the provider bill Medicare, and has a right to appeal Medicare's decision. The beneficiary is responsible for payment if Medicare doesn't pay for the service or item.
  2. The beneficiary may sign the ABN, agreeing to pay for the service. The beneficiary understands he/she is responsible for payment. The provider doesn't bill Medicare and the beneficiary doesn't have the right to appeal Medicare's decision.
  3. The beneficiary may sign the ABN indicating he/she has declined the service. The beneficiary cannot appeal the decision in order to determine if Medicare would have paid.

Other things to consider

  • Blank or partially completed ABNs are not valid. All sections must be completed before the beneficiary signs the notice.
  • The beneficiary's Medicare identification number or social security number may not appear on the ABN.
  • General descriptions of specifically grouped supplies are permitted. For example, "wound care supplies" would be a sufficient description.
  • There must be at least one reason applicable to each item or service as to why the provider believes the item or service isn't covered.
  • ABN's are never required in an emergency or urgent care situation.
  • Blanket or routine ABNs aren't valid. ABNs may not be given to beneficiaries when there is no specific, identifiable reason to believe Medicare will not pay. Giving routine notices for all claims or services is not an acceptable practice.
  • Generic ABNs that state only that Medicare denial of payment is possible, or that the provider never knows whether Medicare will deny payment, aren't valid. The ABN must specify the item or service and a genuine reason why the provider expects Medicare to deny payment.
  • If the beneficiary is unable to understand the notice, a representative of the patient may be asked to sign the notice. The representative should sign his/her own name and write "representative" in parentheses after his/her signature.

For additional information, please review the Centers for Medicare and Medicaid Services (CMS) website at http://www.cms.hhs.gov/BNI.

Medicare - Hospital Benefits

Yale-New Haven Hospital Saint Raphael Campus accepts Medicare insurance.  As a Medicare patient you have certain rights and protections such as the right to be included in decisions about your care and the right to privacy.  The Your Medicare Rights and Protections booklet, available FREE of charge from Medicare, describes the rights you have as a Medicare beneficiary.

You can obtain a copy of this booklet and other important notices/forms detailed below by calling 800.MEDICARE (800.633.4227) or downloading it from the website:  www.medicare.gov.

Hospital in-patient rights

If you're a Medicare patient admitted to a hospital and feel you're being asked to leave sooner than you feel ready, you have the right to ask for an appeal.  This would involve a review of your discharge by an organization called a Quality Improvement Organization (QIO).  Hospitals must give you a notice called "An Important Message From Medicare About Your Rights" that explains this process.  Information on how to contact the QIO is included on the notice.

Here's what else you can find by calling the "800" number or visiting the Medicare site:

  • Information on Medicare eligibility, hospital coverage, cost information and resources to help you pay, all outlined in the Medicare and You handbook -- available online at the site.
  • Free health insurance counseling and personalized help with insurance questions. This is available by calling your State Health Insurance Assistance Program (SHIP). In CONNECTICUT, call 1.800.994.9422 to speak with a counselor.
  • Data on how many people with Medicare had certain procedures and treatments and what Medicare paid, on average.
  • A "Planning your Discharge" checklist. This checklist may assist you in preparing for your discharge to another facility or going home.

Secondary Payer Facts

Have you or a family member who receives Medicare benefits ever wondered why you're asked the same questions by a healthcare provider every time you go in for treatment? While you may find it a bit frustrating, it's actually a federal requirement.

We have to ask: it's the law

Under the Social Security Act of 1965, providers, physicians and other suppliers, including the Yale-New Haven Hospital Saint Raphael Campus are required to ask Medicare patients a series of questions each time the patient receives services to verify the correct order for billing insurance. They are called the Medicare Secondary Payer (MSP) questions and are used to determine if another insurer must be billed before Medicare. The requirement applies to patients with Medicare Part A (hospital insurance) and Part B (medical insurance). The regulations establish the information that hospitals and other providers MUST capture before billing to determine what insurance, Medicare or another, should be billed first.

When Medicare is billed as the primary payer, it confirms that Yale-New Haven Hospital Saint Raphael Campus asked all the mandatory questions and determined that Medicare should in fact, be billed first as the primary payer. While it may seem repetitious, the process actually protects the inappropriate usage of dollars in the Medicare trust fund. We have to ask the questions each time a patient receives services, not only because it's the law, but also because insurance coverage may change from day to day.

Different scenarios, different billing procedures

For example, a Medicare patient may come to the hospital today to receive treatment for diabetes. After asking the MSP questions, we determine Medicare is primary and should be billed first, before any additional insurance. Tomorrow, the patient is in an accident and needs an X-ray. The patient would again be asked the same questions, but this time, it's determined there is liability insurance related to the accident that may pay for the X-ray. That means the liability insurance, not Medicare, must be billed first for services related to the accident.

While we know it takes time for our staff to ask these questions and for patients and families to answer them, we must follow this sometimes time-consuming procedure to comply with the law. We can have the patient answer the questions on paper or the registrar may enter the information directly into the billing system. Either way, the questions must be asked and answered, and the order for billing insurance has to be entered correctly to assure SRHS submits bills accurately.

Get the Fact Sheet

The Centers for Medicare & Medicaid Services (CMS) has published a Medicare Secondary Payer Fact Sheet that you can download Free by clicking here.

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