Medicare Deductible, Coinsurance and Premium Rates for 2016

Medicare Part A (Hospital Insurance): Most people get Part A as soon as they turn 65 without having to pay a premium. The only thing that would prevent a person from being eligible for Part A is failure to pay Medicare taxes while they or their spouse was working.

Medicare Part A is called the hospital insurance because it helps pay for the care a patient receives in a hospital inpatient setting, critical access hospital, skilled nursing facility (SNF), hospice and home health care.  Some Medicare Part A services include:

• Inpatient stay
• Skilled nursing and rehabilitation services, supplies and meals
• Medical and support of hospice (except home care)
• Home health aide services, only part time skilled nursing care, physical, occupational, and speech therapies, durable medical equipment, and supplies

Medicare Part A pays by DRG (Diagnosis Related Groups). DRGs are assigned a classification based on a combination of ICD-9 diagnosis codes, CPT and HCPCS procedure codes, complications or conditions present on admission, discharge status, age and sex. DRGs payments are also based on a certain time period which is an average number of days necessary for adequate treatment.

Deductible

• Deductible per benefit period, $1,288.00

Coinsurance

• For days 1-60, $0.00 per day
• For days 61-90, $322.00 per day
• For days 91-150, $644.00 per lifetime reserve day

Skilled Nursing Facility

• For days 21 thru 100, $161.00 per day

Premiums

• Base Premium - $411.00 per month
• Base Premium plus 10% surcharge - $447.70 per month
• Base Premium with 45% reduction - $226.00 per month (30-39 quarters of coverage)
• Base Premium with 45% reduction and 10% surcharge – $246.40 per month

Medicare Part B (Supplementary Medical Insurance): This part of Medicare is optional to patients one they reach the age of 65 and charges a monthly premium. Part B covers most services not covered by Part A.  Some of these include:

• Physician office visits
• Outpatient hospital services
• Outpatient physical, occupational and speech therapy
• Clinical laboratory services
• Preventative Care
• Durable medical equipment (DME)
• Medical supplies, eyeglasses, and prosthetic devices
• Ambulance services
• For a complete list of items, visit CMS.gov.

Medicare Part B pays by Fee Schedule. A fee schedule is a complete listing of fees used by Medicare on a fee-for-service basis.

Deductible

• Deductible per year, $166.00

Coinsurance

• 20% coinsurance

Premiums

• Held harmless - $104.90 per month
• Not subject to hold harmless - $121.80

It is important to understand Medicare billing requirements which can be somewhat complex. Consider attending training events and opportunities. Providers must ensure that those responsible for preparing and submitting claims to Medicare are aware of proper submission guidelines and regulations.

There are several vendors available to obtain information up-to-date information regarding a patient’s Medicare benefits and current status.

• Patient eligibility
• Claim history
• Benefits
• Medicare Secondary Payer (MSP) Information
• MSP enrollment dates
• Medicare Advantage Information
• Medicare Advantage enrollment dates

 Medical office providers have 365 days from the date the patient is discharged to bill Medicare for payment. Medicare payments are typically made to the medical office 13 calendar days from the date Medicare receives a clean claim.