Medicare, administered by the Center for Medicare and Medicaid Services (CMS), is prmiär a health insurance program for the elderly. (Medicare funds are also used to support certain components of the medical-doctoral training and programs that regulate the quality of care and monitor.) The following groups are eligible through Medicare: US citizens who are ? 65 years old and eligible to use of Social Security, Civil service Retirement and Railroad Retirement people of all ages with end stage renal disease requiring dialysis or transplantation, or amyotrophic lateral sclerosis change Some people who are <65 years old and have certain disabilities nature and scope of areas covered by Medicare benefits regularly with new statutory and regulatory changes (current information at www.medicare.gov). Each state has a State Health Insurance Assistance Program, from which the patient can request assistance to track Medicare plans and select to understand bills and deal with denial of benefits or payment requests. Physicians should understand the basic Medicare rules provide documentation that is used to determine whether patients are entitled to benefits, and refer to legal and social consulting and support services. If a patient's claim is denied, the patient receives a Medicare Summary Notice, informing it does not cover the services or support services Medicare. The rejection of the refund can be reversed by a receivable within 120 days of notification. This requirement must be confirmed by a complaint in a fair administrative hearing procedure in which the Versicherungungsgesellschaft which handles the Medicare claims, considers the case. If the patient with the outcome of this review does not agree, he has the right to a hearing before a judge. The original Medicare plan (sometimes called fee-for-service plan) consists of two parts: Part A (hospital insurance), Part B (medical insurance) of the original Medicare plan is available nationwide. A complete description of the benefits of part A and B and other provisions (called Medicare & You) is available at 800-633-4227 at www.medicare.gov or by telephone. Medicare also provides reimbursement for health services (including prescription drugs) in the form of other models than the traditional single service fees, such as Medicare Advantage plan (Part C), the managed care plan, preferred provider organization plan, private fee-for-service plan includes part D (prescription drug) Each part deals with specific health benefits (see table: financing sources by type of care). Medicare does not cover intermediate or long-term nursing care (except as described below benefits under Part A) nor routine eye, foot or dental examinations. Funding sources for the type of care type of care services Possible source of funding hospital care Inpatient care, incl. Mental health care General nursing and other hospital services and aids drugs that are gerbaucht during hospitalization A semi-private room (a private room unless medically necessary) Meals Medicare part a Medicare Advantage (part C) Medicaid VA * short-term care in a certified Pflegehe Qualified in the (nursing home) care Social Services medications that are used in the apparatus Medical tools and equipment used in the facility nutritional advice physiotherapy and occupational therapy and speech therapy (as needed), to achieve the health goals of the patient transport by ambulance (when other transportation endanger health) to the nearest facility that provides services that are not available in the nursing home a semi-private room meals Medicare part a when the patient temporarily short-term care after a hospital stay need Medicare Advantage when patients temporarily short-term care after hospitalization need Medicaid VA * Outpatient care Costs of doctor, nurse and medical assistant stays in the emergency transport by ambulance (if other transportation endanger health) Outpatient Surgery ((without overnight stay in hospital) Rehabilitation (physiotherapy and occupational therapy and speech therapy) Diagnostic tests such. B. X-ray, laboratory tests) Outpatient mental health care Outpatient dialysis obtaining a second opinion if surgery is recommended, and a third if the opinions differ in patients with diabetes: Diabetes aids, training for self-application, eye exams and nutritional counseling to stop smoking permantente medical devices (eg. as wheelchairs, hospital beds, oxygen, Gehböcke) Medicare part B Medicare Advantage Medicaid VA * Home care Personal care, incl. help with eating, bathing, toileting and dressing qualified part-time nursing physiotherapy and occupational therapy and speech therapy at home and health assistance social services Medical Supplies (z. B. dressings), but no versc hreibungspflichtigen drugs Medicare Part A when the patients are domesticated bound and daily skilled part-time care or rehabilitation need Medicare Part B Medicare Advantage Medicaid VA preventive screening tests for prostate and colon cancer mammography Papanicolaou (Pap) test bone density measurements glaucoma Untesruchungen influenza , pneumococcal and hepatitis B vaccination diabetes screening cholesterol screening Medicare part B Medicare advantage Medicaid VA * additional benefits Prescription drugs eyeglasses hearing aids Medicare advantage Medicare care Part D (plans for prescription drugs) Medicaid in some states VA * Long-term care in an assisted living community varies widely from community to community meals help with everyday activities Some social and recreational activities Some health care services Medicaid in some states (partial coverage) VA * in some situations long-term care in a skilled nursing facility (nursing home) varies from state to state Medicaid VA * hospice care Physical care and psychiatric counseling room and board Medicare only during inpatient respite care and short hospital stays Part A Medicare Advantage * vary the rules for the granting of various services for the Veterans Administration and change frequently. VA = Department of Veterans Affairs. Part A More than 95% of people ? 65 years enrolled in Part A. Part A is supported by a payroll tax, which is collected by the working population; there is provided a pre-paid hospital insurance for Medicare-qualified retirees. Are entitled i. Gen. Only persons who receive monthly Social Security payments, and most beneficiaries do not pay premiums. However, premiums may be paid if the persons or their spouses have worked <40 quarters in a job that is Medicare-eligible (ie, they or their employers have paid the payroll tax, which is required by the Federal Insurance Act [FICA] ). Premiums depend on how long the people were employed; in 2013 it was $ 243 / month for individuals with a qualified employment about 30 to 39 quarters, or $ 441 / month for individuals with 0-29 quarters of skilled employment. People with income and assets below certain thresholds are eligible for financial assistance through the Medicare Savings Programs qualified (Medicaid: Medicare Savings Programs). Part A covers under the u.g. Circumstances following from: Inpatient hospital treatment care after hospital discharge in a nursing home or rehabilitation facility care in a hospice nursing care Limited Limited home care nursing in a hospital or a skilled nursing home is paid for basic or performance periods. A benefit period begins at admission of a person into a facility and ends when the person over a period of 60 consecutive days was not at the facility. If a person after the 60 days is taken up again begins a new period of performance, and another deductible must be paid. If a person is resumed within <60 days, an additional deductible is not paid; However, the hospital or institution may not receive payment in full for the second recording. There is no limit to the number of power cycles. Medicare Prospective Payment system determine what is Medicare for every aspect of care, they cover (eg. As for inpatient hospital care, skilled nursing in a nursing home or home care) pay. Inpatient hospital treatment accordance with Part A of the recipient pays only a deductible for the first 60 days with full coverage of the power period; the deductible is set annually ($ 1,184 in 2013). the hospital stay lasts longer than 60 days, the beneficiary pays a daily payment, equivalent to one quarter of the deductible (in 2013 $ 296 per day for 61-90 days). Exceeds the hospital 90 days the recipient pays a daily payment equal to half of the deductible (in 2013 $ 592 per day for 91 to 150 days). The day 91-150 during a hospital stay are referred to as reserve days. Part A services include 60 reserve days for use after a 90-day reference period throughout the life. The 90-day subscription period is renewed annually, but the 60 reserve days are not renewable and can be used only once in the life of beneficiaries. The payment of such additional days of hospital care is automatic after the 90-day benefits have been exhausted, unless the other hand, the recipient chooses (and saves the reserve day for a later date). If not all the reserve days are available, the recipient is responsible for all costs for more than 150 days. Part A covers virtually all medically necessary hospital services, with the exception of a limited coverage for inpatient psychiatric care. Part A pays for a semi-private room or when medically necessary, a private room, but not for amenities. Other covered services include discharge planning and medical-social services such. For example, the establishment of eligibility for public programs and referral to agencies of the community. The prospective payment system determines the payments for inpatient hospital care based on diagnosis-related group (DRG). The DRG is determined by the main diagnosis of the recipient with some adjustments to age, severity, gender, co-morbidities and complications. Hospitals receive regardless of their actual maintenance expenses a fixed reimbursement for a particular DRG. So the financial gain or loss of a hospital depends in part on the length of stay and the cost of diagnosis and treatment for each patient. With the prospective payment system of financial pressure on early discharge and limited interventions with the medical assessment can compete. Can not be safely discharged home or to a nursing home, a patient because there is no bed available, Medicare pays typically a relatively small amount per day for an alternative Pflegeniveau.Stationäre care in a skilled nursing home is the cover of qualified care and qualified rehabilitation complex and can change every year. These services are covered only if they are introduced directly at or shortly after discharge from a hospital. The performance period is usually <1 month (the specific repayment duration depends on the documented improvement in the patient or its functional levels from state). In 2013, the first 20 days were completely covered; the following 80 days were indeed covered, but required an additional payment of $ 148 / day. The services are limited to 100 days per benefit period. The Medicare Prospective Payment system classifies patients in nursing facilities with a system of resource utilization groups (RUGS III), which is based on seven categories: Special Care Rehabilitation Clinically complex problems Severe behavioral disorders Impaired cognition reduced physical functioning need for extensive services These categories reflect the type and quantity of resources resist, which are expected to cost the care of a patient. They are divided primarily based on the functional dependence of the patient. This system is updated annually. The goal is to increase efficiency and to avoid excessive payments for patients who require little care. Prospective per diem rates cover routine, complementary and capital costs of caring for a patient in a nursing home. RUGS III used data from the Minimum Data Set (MDS), the prescribed standard tool for evaluating patients in skilled nursing facilities. MDS requires continuous monitoring of the patient, whereby the treatment results are associated with categories RUGS können.Häusliche care Part A comprises i. Gen. certain home health services (eg. as part-time or intermittent skilled nursing care, home nursing care workers in conjunction with qualified care, physical and occupational therapy, speech therapy), if they are part of a medically approved plan of care for a housebound patients. However, the level and duration of the refund are limited. The recent introduction of a prospective payment system now limits the refund amount. Medical care is covered when they settled wird.Hospizdienste from a Home Health Agency medical and supportive services in the terminal stage of the disease are usually covered if a doctor certifies that the patient is terminally ill (estimated life expectancy of 6 months). However, the patient hospice care must support instead of standard Medicare benefits wählen.Pflegerische care in daily activities (ADL) such as eating, dressing, toileting and bathing is only covered at home, albeit a skilled nursing (services of a professional nurse or a therapist care plan) is required as part of a medical authorized home. Such nursing care in a nursing home is covered when it is part of an acute or rehabilitation care after hospital discharge. Part B The federal government pays an average of about 75% of the cost for Part B beneficiaries pay 25%. Part B is optional; although recipients of Social Security are automatically enrolled at the age of 65 years in Part B, they reduce possibly the cover (95% decide to keep the Part B coverage). All beneficiaries pay a monthly premium, so by income variiert- $ 104.90 in 2013 for new beneficiaries whose income in 2011 was $ 85,000 ? (? $ 170,000 when they were married and had agreed on a joint refund). Premiums are higher for people with higher incomes; in 2013 they increased to a maximum of $ 335.70 for individuals with incomes> $ 214,000 in 2011 was (> 428,000 $ if they were married and had agreed on a joint refund). The premiums are automatically deducted from monthly Social Security check. People who reduce the coverage, but change their mind later have to pay a premium, basis for calculation is the period by which the enrollment was delayed. The premiums typically rise by 10% for every year, by which the registration is delayed; except for persons who are covered by a group insurance through their employers, the labor Gerber of their spouse or a family member; they pay no fee if they are after the end of employment or health insurance coverage (whichever comes first) to enroll. Most states have Medicare Savings Programs (Medicaid: Medicare Savings Programs), pay the Part B premium to persons who meet certain financial qualifications. Participants can terminate the coverage at any time, but must pay a surcharge on the premium if they occur again. What is covered Part B covers a percentage of: costs of medical services; with certain limitations outpatient hospital treatment (. eg support in the emergency department, outpatient surgery, dialysis); outpatient physical and occupational therapy as well as speech therapy; diagnostic tests, including portable X-ray at home. Prosthetics and Orthotics and permanent medical equipment for home use. Is recommended surgery, Part B covers some of the cost of an optional second opinion and, if they are different opinions, a third opinion from. Part B also includes medically necessary ambulance services, certain services and resources that Part A does not cover (z. B. colostomy bag, prostheses), manipulation of the spine from a licensed chiropractors at nachgeweisener by X subluxation, drugs and dental care when these are considered as part of a medical treatment necessary optometric services in connection with lenses for cataract, smoking cessation counseling and services of physician assistants, nurses, clinical psychologists and clinical social workers. Outpatient mental health care is covered with certain restrictions. Drugs and biologicals that can not be used by patients themselves (eg. B. iv given medication), some oral cancer drugs and certain medications for hospice patients is covered by Part B of the patient but in a managed care program enrolled, covers part B not from usually outpatient drugs. Part B includes several preventive services, incl. Determination of bone mass, serum cholesterol screening, abdominal aortic aneurysm screening, diabetes services (screening, tools, self-application training and eye and Fußuntersuchungen), colorectal cancer screening, prostate cancer screening and tests for prostate-specific antigen, a physical initial examination (the “Welcome to Medicare ‘inquiry), glaucoma screening, vaccinations (influenza, pneumococcal, hepatitis B), mammography and Papanicolaou (Pap) tests. Part B does not cover routine eye, foot or dental Untersuchungen.Erstattung to physicians According to Part B of the doctors can choose to become directly from Medicare (assignment) paid, and they receive 80% of the allowable charge directly from the program, once the deductible is met. If doctors accept assignment, their patients are only responsible for paying the deductible. Doctors who accept the transfer of the Medicare payments not (or only selectively), can provide up to 115% of the allowable fee charged to the patient; the patient will receive a refund (80% of the allowable charge) from Medicare. Doctors are fined if their fees exceed the maximum permissible amounts of Medicare. Doctors who do not accept the transfer of the Medicare payments must present the patient in amounts> $ 500 a written estimate for elective operations. Otherwise, the patient may require later by the doctors a refund of any amount above the allowable fee. Medicare payments to physicians were inadequate criticized for the time required for the determination of the physical and mental status and medical history with family members. In January 1992, a Medicare fee schedule for a resource-based relative scale was put in place for medical services to try to resolve this issue. The effect of the scale on patient care and medical practice have yet to grasp, but few doctors are satisfied. Paperwork and time for documentation have increased. Part C (Medicare Advantage Plans) This program (formerly Medicare + Choice) offers several alternatives to traditional fee-for-service programs. The alternatives are provided by private insurance companies, Medicare pays these companies a fixed amount for each beneficiary. Several different types of plans are available; they include managed care, preferred provider organizations, private fee-for-service services, medical savings accounts and plans for special needs. Medicare Advantage plans have at least the level and nature of the benefits of Medicare A and B covering However Medicare can Advantage plans additional services include (z. B. coverage of dentures, prescription drugs or routine glasses), although the subscriber an additional monthly premium for pay the additional services. The plans differ in whether the participants have Free choice of doctor or hospital whether they can retain a refund by the employer or the union and what costs are to be paid out of pocket, incl. The amounts (if any) for a premium incurred if they pay a part B premium and how high their deductibles and co-payments are her. Medicare Advantage plans are available in many, but not all parts of the country. Part D Medicare Part D helps cover the cost of prescription drugs. It is optional. The plans provided by insurance or other private companies that work with Medicare. There are over 1,000 nationwide plans. The premiums usually rise by 1% for each month by which the people delay enrolling after they are first eligible for Medicare. Covered drugs The plans differ with respect to. The drugs they cover (formularies) and respect. Of pharmacies that can be taken advantage of. However, the drug list are ? 2 effective drugs in the categories and classes of drugs that are prescribed to users of Medicare most often. The drug lists must contain all available drugs of the following six categories: antiepileptics, antidepressants, anti-retroviral drugs, antineoplastic agents, antipsychotics and immunosuppressants. The drug lists can over time (often annual) change. The drug lists must also provide for an appeal procedure, to be approved over the non gelistetete medication if necessary können.Nutzen and Costs The costs in 2014 for the basic insurance amount (drug costs for Medicare Part D in 2014): premiums: Premiums vary by plan and incomes are, but average around $ 40 / month for those with incomes ? $ 85,000 / year (? $ 170,000 for married couples with joint taxation); People with higher incomes pay an additional premium of $ 12.10 to $ 69.30 / month. Annual Deductible: The patients pay the first $ 310 for drugs (one plans have no deductible). Surcharges: patients pay 25% of drug costs (cost) for the next $ 2,540 in drug costs (after deductible of $ 310). Thus, the co-payment for the first $ 2,850 of drug costs $ 635 is in addition to the $ 310 deductible. Coverage gap: After the first $ 2,830 of drug costs, the people have a higher proportion (47.5% for brand-name drugs, 72% for generics) pay of drug costs up to a self to be paid total of $ 4550th Reduced payments: Once the personal contribution limit is reached, Medicare pays about 95% of the additional drug costs until the end of the year. The cost of the coverage gap will decline each year until at least 2020. Many companies also offer improved plans that offer more reimbursement (eg. As lower deductibles or co-payments), although these plans have higher monthly premiums. Specific drug costs may depend on whether the drug is on the drug list of the plan and whether the prescription from a pharmacy in the network of the plan (if the plan at all one has) is satisfied. People with low income and low assets (eg. As those that are fully covered by Medicaid, which belong to a Medicare Savings Program or receive Supplemental Security Income) may be eligible for financial assistance with premiums, deductibles and co-payments. In addition to providing assistance with insurance, many states have state pharmacy assistance programs, the participating based on a combination of need, age and illness the person to the cost of prescription drugs; Information about these programs is available from the State Helath Insurance Assistance Program. Drug costs for Medicare Part D in the year, 2014.