In this article: Discover the 5 key factors medical staff need to know about Medicare to help patients navigate their coverage effectively. Learn how understanding Medicare can improve patient care and streamline processes in healthcare settings.
For healthcare providers and medical staff, understanding Medicare can help you deliver the best care while ensuring patients navigate their coverage effectively.
Medicare is a complex system with multiple parts, and many patients rely on medical professionals to help guide them through the details—whether they’re asking questions like “What is Medicare Advantage?” or trying to understand their costs for medical services or treatments done under their specific plan.
While Medicare primarily serves seniors over 65, it also covers younger individuals with specific disabilities or health conditions.
Knowing the ins and outs of this program can help streamline billing, assist patients quicker, and avoid coverage issues that could delay care.
Here are five key factors medical staff should be familiar with regarding Medicare.
Understanding the Different Parts of Medicare
Medicare has four primary parts, and knowing the differences between them can help staff and patients when providing accurate information and care:
- Medicare Part A covers hospice, inpatient hospital stays, skilled nursing facility care, and some home health services. It is premium-free for most beneficiaries who have worked and paid Medicare taxes for at least 10 years.
- Medicare Part B covers outpatient care—so, that’s things like doctor visits, lab work, outpatient surgeries, and durable medical equipment. It has a monthly premium and a yearly deductible. Part B covers 80% of approved services, leaving patients responsible for the remaining 20% of coinsurance.
- Medicare Part C (often referred to as Medicare Advantage) is an alternative to Original Medicare (Parts A and B) through private insurance companies. It is often bundled to include drug coverage and sometimes additional benefits. Medical staff should be aware that Medicare Advantage plans operate more like HMOs or PPOs, with network restrictions and prior authorizations.
- Medicare Part D is prescription drug coverage. Each plan has its own formulary (list of covered drugs), and each plan is specific regarding what an enrollee’s out-of-pocket costs will be.
Enrollment Periods and Deadlines
Medicare enrollment isn’t automatic for everyone, and missing deadlines can lead to penalties or gaps in coverage for your patients transitioning to Medicare.
Medical staff can provide basic guidance to patients about the main enrollment periods:
- Initial Enrollment Period (IEP) occurs when a person is first eligible for Medicare, typically around their 65th birthday. It lasts for seven months (three months before their birthday, the month of their birthday, and three months after).
- Special Enrollment Periods (SEPs) allow patients to enroll in or change plans outside the standard enrollment periods under certain circumstances, such as losing employer-based health insurance. Understanding these periods helps patients transition, typically from employer-sponsored insurance to Medicare, with no issues or lapses in coverage.
- Medicare Fall Open Enrollment (Annual Election Period) occurs annually from October 15th to December 7th. This window allows Medicare beneficiaries to make changes to their Part D or Medicare Advantage plans. Since Advantage plans can change every year, and providers can choose whether or not to accept these plans, communication about this enrollment window can be helpful.
- General Enrollment Period (GEP) runs from January 1st to March 31st each year for those who missed their initial enrollment period and do not qualify for a Special Enrollment Period. This window is for Original Medicare only (Part A and/or Part B). Coverage begins the month after you apply, and late penalties may have been accrued.
Medicare Doesn’t Cover Everything
Medical staff should try to educate patients about Medicare’s limitations.
Some services that Medicare typically does not cover include:
- Long-term care (custodial care in a nursing home or assisted living facility)
- Routine dental, vision, and hearing care
- Overseas medical expenses
- Cosmetic surgery
While some Medicare Advantage plans may choose to offer coverage for additional services like dental or vision, Original Medicare does not.
Patients often assume Medicare will pay for things like routine checkups at the dentist or eyeglass prescriptions, only to be caught off guard when these services aren’t covered.
Helping patients understand these gaps allows them to plan for additional insurance or set aside funds to cover these costs.
Billing and Documentation Requirements Are Specific
Accurate Medicare billing and compliance are critical for medical staff.
Unlike private insurance, Medicare has strict guidelines regarding claim submissions, and errors can result in delays, denials, or audits.
One of the main elements is ensuring that services and treatments are considered medically necessary and properly documented as such.
Medicare will only cover services that meet its criteria for medical necessity, and proper documentation is required to support the billing of services.
Medicare billing is also subject to specific timeframes.
Claims must be filed within a certain time from the date of service, and missing this deadline could mean your facility forfeits reimbursement.
Coordination of Benefits
Many Medicare beneficiaries have additional health coverage through employer-sponsored plans, Medicaid, or retiree insurance.
In these cases, you need to understand the coordination of benefits (COB) to determine which payer is primary and which is secondary.
Medicare generally pays first if the patient is retired, but there are exceptions.
Coordination of benefits can affect claims processing and patient billing, so ensuring that COB information is accurate in the patient’s file helps to avoid issues like billing errors, delayed payments, and miscommunication regarding a patient’s out-of-pocket obligations.
Get Prepared
Whether they are helping patients make decisions about their coverage, avoiding billing issues, or ensuring compliance with Medicare’s guidelines, medical staff can enhance their ability to support Medicare beneficiaries by staying knowledgeable and well-versed in these matters.
In doing so, staff can continue to provide the best possible care for beneficiaries.
