What Medicare covers

On this page

What does Medicare cover? What's not covered by Medicare?

What does Medicare cover?

The benefits you receive from Medicare are based on a Schedule of fees set by the Australian Government. Doctors may choose to charge more than the Schedule fee. The Medicare Benefits Schedule (MBS) lists all the Medicare item numbers.

Better Access to Mental Health Services

The Australian Governments Better Access to Psychiatrists, Psychologists and General Practioners through the Medicare Benefits Schedule initiative provides a range of Medicare subsidised services. This includes services provided by psychiatrists and General Practitioners, and psychological interventions provided by psychologists and appropriately trained social workers and occupational therapists. Further information about this initiative is available on the Department of Health and Ageing website.

Out-of-hospital services
Medicare provides benefits for:

consultation fees for doctors, including specialists tests and examinations by doctors needed to treat illnesses, including X-rays and pathology tests eye tests performed by optometrists most surgical and other therapeutic procedures performed by doctors some surgical procedures performed by approved dentists specified items under the Cleft Lip and Palate Scheme specified items for allied health services as part of the Chronic Disease Management program - call Medicare on 132 011 for more information.

You can choose the doctor who treats you for out-of-hospital services.

In-hospital services
Public Patient

If you choose to be admitted as a public (Medicare) patient in a public hospital, you will receive treatment by doctors and specialists nominated by the hospital. You will not be charged for care and treatment, or after-care by the treating doctor. Private Patient If you are a private patient in a public or private hospital, you will have a choice of doctor to treat you. Medicare will pay 75 per cent of the Medicare Schedule fee for services and procedures provided by the treating doctor. If you have private health insurance some or all of the outstanding balance can be covered. You will be charged for hospital accommodation and items such as theatre fees and medicines. These costs can also be covered by private health insurance.

What's not covered by Medicare?

Medicare does not cover such things as:

private patient hospital costs (for example, theatre fees or accommodation) dental examinations and treatment (except specified items introduced for allied health services as part of the Chronic Disease Management (CDM) program ambulance services home nursing physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology (except specified items introduced for allied health services as part of the Chronic Disease Management (CDM) program acupuncture (unless part of a doctor's consultation) glasses and contact lenses hearing aids and other appliances the cost of prostheses (except External Breast Prostheses covered by the External Breast Prostheses Reimbursement Program) medicines (except for the subsidy on medicines covered by the Pharmaceutical Benefits Scheme) medical and hospital costs incurred overseas medical costs for which someone else is responsible (for example a compensation insurer, an employer, a government or government authority) medical services which are not clinically necessary surgery solely for cosmetic reasons examinations for life insurance, superannuation or membership of a friendly society eye therapy

You can arrange private health insurance to cover many of these servic

Medicare forcing hospitals to improve their customer service In the midst of arguments on the Affordable Health Care programs, it is interesting to delve into this years Medicare push for improved customer service in the hospital venue. Beginning in October, Medicare will hold one percent of their regular reimbursements based on performance. With payments that will total more than $50 million, United States health-care is being forced to improve the quality of their care. The survey is called Hospital Consumer Assessment of Health-care Providers and Services (HCAHPS) and contains 27 pertinent questions about a patients hospital experience. Here is just a sampling of what patients are asked:

Did the nurses and doctors communicate well during your hospital stay? Was your pain well-controlled? Was your room clean? Was the hospital quiet at night? Was the food prepared well, and how was the menu? When discharged from the hospital, did you receive clear follow-up instructions?

Some hospitals are really taking the new Medicare initiative seriously. They are demanding the entire hospital staff attend customer satisfaction seminars. Where many patients remember a physician entering a patients room and treating that patient as if he were merely a medical object and showed little compassion much less any bedside manner, that entire mindset has been changing. Although it is a subjective opinion of what a patient perceives is compassionate, no one can deny the hospital that implements programs such as massage therapy, reflexology, and music therapy. Hospitals have even improved their menus and the way food is presented to patients. In Detroit based hospital Henry Ford, dont be surprised to see such menu choices as tilapia and chicken piccata. Room service and VIP lounges have been introduced with the hopes that patients will give the hospital higher marks. Hospitals will be reimbursed based on 70 percent of actual patient quality care and 30 percent based on patient satisfaction. So besides adding luxurious extras to enhance the rather scary and unsettling hospital experience for patients, besides employing extra customer service training, hospitals are now hiring patient experience consultants to help deal with complaints and add the more compassionate touch to serious medical care. Watch some of the commercials on television where the words compassion, treating the whole patient, and a completely new genre of gentle and personalized medical services are offered often taking the place of the impersonal green and white walls of hospitals in the past. What happens however, in the poorer hospital areas where massages and high paid chefs are not an option in the medical hospital budget? There comes the practical argument that the quality of

care is the most important aspect of healing a patient. These facilities will lose money on Medicare reimbursement because even poor patients want to be treated as a whole person. So far only 67 percent of the patients polled gave top grades to hospitals. Now that is food for thought.

How to choose a Medicare Advantage plan

Read more here: http://www.thenewstribune.com/2012/05/06/2133572/how-to-choose-a-medicareadvantage.html#storylink=cpy

WHAT IS IT? Sometimes called Medicare Part C, Medicare Advantage plans are government-approved health plans sold by private insurance companies that you can choose in place of original Medicare. The vast majority of Advantage plans are managed-care policies such as HMOs or PPOs that require you to get your care from a network of providers. If you join an Advantage plan, the plan will provide all of your Part A (hospital insurance) and Part B (medical insurance) coverage some plans even offer extra benefits like vision, dental and hearing. And most plans include Part D prescription drug coverage too. HOW TO CHOOSE To help you choose a plan, a good first step is to call your doctors and find out which Advantage plans they accept, and which ones they recommend. Then go to the Medicare Plan Finder tool at medicare.gov/find-a-plan and compare those options. When comparing, consider: Total costs: Look at the plans entire pricing package, not just the premiums and deductibles. Compare the out-of-pocket maximums plus the copays and coinsurance charged for doctor office visits, hospital stays, diagnostic tests, visits to specialists, prescription drugs and other medical services. This is very important because if you choose an Advantage plan, youre not allowed to purchase a Medigap supplement policy, which means youll be responsible for paying these expenses out of your own pocket. Drug coverage: Check the plans formulary the list of prescription drugs covered to be sure all the medications you take are covered without excessive co-pays or requirements that you try less expensive drugs first. Extra benefits: Many Advantage plans include dental, vision and hearing benefits, but they are often limited. Out-of-network coverage: Since most Advantage plans limit you to using in-network doctors only, find out whats covered if you have an emergency outside your network area.

Locations: If you dont use any particular doctors and you live in a rural area, make sure the doctors in the plans youre considering are located near you. Also check to see if the hospitals, home health agencies and skilled nursing facilities that the plan covers are nearby too. Retiree benefits: If you have coverage from a former employer, speak with the benefits manager, because signing up for Advantage may void your retiree coverage. GET HELP You can get help by calling Medicare at 800-633-4227. They can do the comparing for you over the phone, and enroll you when youre ready. Another good resource is your State Health Insurance Assistance Program, which provides free Medicare counseling. Visit shiptalk.org, or call 800-677-1116 to locate a counselor in your area. And check out the HealthMetrix Research Cost Share Report at medicarenewswatch.com. This service chooses the best Advantage plans based on health status.

Medicare Outpatient Hospital Prospective Payment System

How does Medicare define inpatient and outpatient?
An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally a person is considered an inpatient if formally admitted as an inpatient with the expectation that he will remain at least overnight and occupy a bed even though it later develops that he can be discharged or transferred to another hospital and does not actually use a hospital bed overnight. (Hospital Manual, Publication 10, Chapter Two, Section 210 Coverage of Services) A hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. When a patient with a known diagnosis enters a hospital for a specific minor surgical procedure or other treatment that is expected to keep him in the hospital for only a few hours (less than 24), he is considered an outpatient for coverage purposes regardless of: the hour he came to the hospital; whether he used a bed; and whether he remained in the hospital past midnight. (Hospital Manual, Publication 10, Chapter Two, Section 230.1 Outpatient Defined and Section 210 Covered Inpatient Hospital Services)

What is the Medicare Outpatient Hospital Prospective Payment System?

The Outpatient Prospective Payment System (OPPS) is the payment system by which Medicare reimburses hospitals for providing outpatient care to beneficiaries. Under this system, which began in 2000, Medicare sets prices for over 700 Ambulatory Payment Classifications, or APCs. These payment rates, also referred to as APCs, are established for groups of procedures or services based on a set of relative weights, a conversion factor, and an adjustment for geographic differences.

How do APCs work?

Procedures, services, and some drugs and devices furnished in outpatient departments are identified by a Healthcare Common Procedure Coding System (HCPCS) code (which includes the AMAs CPT codes). HCPCS are grouped into over 700 ambulatory payment classifications (APCs). For the most part, these APCs group items and services that are clinically similar and use comparable amounts of resources. Within each APC, the Centers for Medicare & Medicaid Services (CMS) packages integral services and items with the primary service. For example, the payment amount for an APC for a surgical procedure includes operating and recovery room services, most pharmaceuticals, anesthesia, and surgical and medical supplies. A hospital outpatient facility may receive payment for more than one APC. However, for most surgical APCs, the primary APC will receive full amount while the secondary APC(s) amount will be reduced by 50 percent. Always keep in mind, the more efficiently care is delivered, and the better the documentation, the greater the operating margin will be for the hospital.

How is the APC payment rate determined?

The payment rate associated with each APC is determined by multiplying the relative weight for the APC by a conversion factor (the conversion factor translates the relative weights into dollar amounts). To account for geographic differences, the labor portion of the payment rate (60 percent) is adjusted by the hospital wage index. The OPPS allows for additional payments for certain pass-through drugs, devices, and biologicals, qualifying new technologies, and for outlier cases involving high-cost services. The APC payment rate is the total amount the hospital will receive from Medicare and the beneficiary. These rates are updated annually and take effect in January.

What is transitional pass-through?

It is a payment methodology developed by CMS to reimburse hospitals for 2 to 3 years for certain medical devices that meet a certain criteria. During this period, CMS will gather data on the costs of these devices to enable these costs to be incorporated into an appropriate APC. Passthrough codes were implemented in 2000 with most of them expiring on January 1, 2003. Bear in

mind that transitional pass-through applies only to the hospital outpatient setting and is temporary in nature.

Do any Stryker products have transitional pass-through payment?

Yes. The DEKOMPRESSOR qualifies for transitional pass-through. Hospitals use the following code to report the use of the device:
C2614 Probe, Percutaneous Lumbar Discectomy

How is payment calculated for a transitional pass-through payment?

Pass-through payment is determined by adjusting the hospitals charges to cost using the hospital specific cost-to-charge ratio (CCR), as determined by CMS. For example, if a hospital charges $5,000 for the device and their CCR is .50, then the hospital will receive $2500 for the device in addition to the APC payment.

What are APC Rates for frequently performed orthopaedic procedures?

CPT 27407 29827 62287 0051 0041 0220 APC Description Repair of Knee Ligament Arthroscopy Rotator Cuff Repair Percutaneous Diskectomy 2004 National Avg. APC Rate $1883.14 $1493.98 $903.28

How can a hospital get reimbursed by Medicare for the cost of the device?
When a procedure is performed on an outpatient basis, if there is no transitional pass-through payment associated with the device, the payment for the device is part of the APC payment for the surgical procedure.

For questions, please contact Stryker Reimbursement Services at 800-698-9985. CPT codes, descriptions and material only are copyright 2002 American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT.

Every reasonable effort has been made to ensure the accuracy of the information in this guide. However, the ultimate responsibility for coding and claims submission lies with the provider of services (e.g., physician, hospital or other facility). Stryker Orthopaedics makes no representation, guarantee or warranty, expressed or implied, that this report is error-free or that the use of this information will prevent differences of opinion with third-party payers and will bear no responsibility or liability for the results or consequences of its use. Our recommendations do not guarantee coverage or payment of the technology or procedure. Providers should accurately report the patients condition and the services and supplies they provide to their patients. Reimbursement is dynamic. Coding and payment rates may change from time to time. Providers should also consult with payers and follow their guidelines as appropriate.

8 Things to Consider When Choosing or Changing Your Coverage

1. Coverage
Are the services you need covered?

2. Your other coverage

Do you have, or are you eligible for, other types of health or prescription drug coverage (like from a former or current employer or union)? If so, read the materials from your insurer or plan, or call them to find out how the coverage works with, or is affected by, Medicare. If you have coverage through a former or current employer or union or other source, talk to your benefits administrator, insurer, or plan before making any changes to your coverage. If you drop your coverage, you may not be able to get it back.

3. Cost
How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Whats the yearly limit on what you pay outof-pocket? Your costs vary and may be different if you dont follow the coverage rules.

4. Doctor and hospital choice

Do your doctors and other health care providers accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?

5. Prescription drugs

Do you need to join a Medicare drug plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plans formulary? Are there any coverage rules that apply to your prescriptions?

6. Quality of care
Are you satisfied with your medical care? The quality of care and services given by plans and other health care providers can vary. Get help comparing plans and providers

7. Convenience
Where are the doctors offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records prescribe electronically?

8. Travel
Will the plan cover you in another state or outside the U.S.?