SUPPLEMENTARY MEDICAL
Posted by admin on October 13th, 2008Persons who decline coverage but later change their minds must pay a surcharge based on how long they delayed enrollment. Participants may discontinue coverage at any time but must pay a surcharge on the premium if they re-enroll.
Part B covers physician services and physician-prescribed services, such as hospital outpatient services, including emergency department care and day surgery; physical, occupational, and speech therapy; diagnostic tests including portable x-ray services in the home; and durable medical equipment for home use. If surgery is recommended for a patient, Part B covers part of the cost of a second and even a third opinion.
In addition, Part B covers medically necessary ambulance services, certain services and supplies (colostomy bags, prostheses) not covered by Part A, drugs and biologicals that cannot be administered by the patient, spinal manipulation by a licensed chiropractor for subluxation demonstrated on x-ray, dental services deemed necessary to medical treatment, optometry services related to providing lenses for cataracts, and the services of physician assistants, nurse practitioners, clinical psychologists, and clinical social workers. Outpatient mental health care, with certain limitations, is covered. A complete description of Part B services and other provisions is available in The Medicare Handbook, updated annually.
Under Part B coverage, Medicare determines the allowable charge for each service and pays 80% of the allowable charge, aftei the annual deductible is paid. If the billed charge equals the allowable charge, the patient pays the remaining 20%. If the billed charge exceeds the allow-
able Medicare charge, the patient pays 20% of the allowable charge and the amount above the allowable charge, up to a maximum percentage of the allowable charge; in 1993, the maximum was 115%. Physicians, whether they participate in Medicare Part B or not, whose charges exceed the maximum Medicare fees are subject to fines.
Physicians may or may not participate in Part B of the Medicare program. A participating physician takes assignment on all Medicare patients. (Assignment means that beneficiaries assign their right to receive payment from Medicare to the physician and that the physician receives payment—80% of allowable charges—directly from the program.) A nonparticipating physician either does not take assignments or takes them selectively. If a physician does not take an assignment, Part B pays the 80% to the patient, who is then responsible for all payments to the physician. Whether participating or not, the physician must send the claim to Medicare and must bill the patient for the Part B deductible ($100 in 1993).
A physician who does not take assignment for elective surgery must give the patient a written estimate in advance if the total charge is more than $500. If the physician does not provide an estimate, the patient can later claim a refund from the physician for any amount paid over the allowable charge.
The Medicare payments to physicians have been criticized for being inadequate compensation for the time involved in giving physical and mental status examinations and obtaining the patient history from family members. A Medicare fee schedule based on a resource-based relative value scale (RBRVS) for physician services became effective in January 1992 to address this concern. The effects of the Medicare fee schedule on patient care and on the practice of geriatric medicine remain to be seen.
The services covered by Parts A and B can be provided through a health maintenance organization (HMO). Medicare pays the HMO a lump sum per enrollee (capitation) based on the average expenditures for Medicare beneficiaries in the geographic area. If the income from Medicare is greater than the expenses, the HMO must share part of the excess with its Medicare members by providing services not covered by Medicare (eg, preventive medical services) or by eliminating cost sharing.
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