Medicare: Appeals Process – How does it work?

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Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. There are five levels in the Medicare Part A and Part B appeals process. The levels are:

Medicare: Proposed Rule for Payment under the Ambulance Fee Schedule

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Proposed Rule for Payment under the Ambulance Fee Schedule (AFS) published 5/26/06 (See AFS Regulations and Notices link.) Section 4531 (b) (2) of the Balanced Budget Act (BBA) of 1997 added a new section 1834 (l) to the Social Security Act which mandated the implementation of a national fee schedule for ambulance services furnished as a benefit under Medicare Part B.

Medicare and the American Recovery and Reinvestment Act (ARRA

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On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act (ARRA), which delayed the phase-out of the hospice wage index budget neutrality adjustment factor (BNAF) for FY 2009. Therefore we are posting a revised copy of the FY 2009 wage index (see Downloads section below), which includes a full (unreduced) BNAF. Please also see CR 6418 (Transmittal 1701, dated March 13, 2009 ) (see Downloads section below) for more information on the revision to the FY 2009 wage index.

The following two categories of dental services are excluded from Medicare coverage

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A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.

Medicare Service – Statutory Dental Exclusions

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Section 1862 (a)(12) of the Social Security Act states, “where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.”

Many seniors do not receive recommended preventive and primary care

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Under health insurance reform, a senior would not pay anything for a screening colonoscopy or other preventive services. Reform will eliminate any deductibles, copayments, or other cost-sharing for obtaining preventive services, making them affordable and accessible

Ending overpayments to private insurance companies that cost all Medicare beneficiaries

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The federal government pays private insurance companies on average 14 percent more for providing coverage to Medicare Advantage beneficiaries than it would pay for the same beneficiary in the traditional Medicare program.

New Tips to Prevent Medical Identity Theft and Medicare Fraud

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Secretary of Health and Human Services Kathleen Sebelius and Assistant Attorney General Tony West today highlighted the Obama Administration’s work to fight Medicare Fraud and released new tips and information to help seniors and Medicare beneficiaries deter, detect and defend against Medical identity theft.

Medicare: Transparency and Open Government by President Obama

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My Administration is committed to creating an unprecedented level of openness in Government. We will work together to ensure the public trust and establish a system of transparency, public participation, and collaboration. Openness will strengthen our democracy and promote efficiency and effectiveness in Government.

HHS Highlights Innovative New Open Government Initiatives

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Part of Open Government Commitments in Service of National Priorities Programs Are Result of Accessible Federal Decision Making Process — HHS Secretary Kathleen Sebelius announced today three innovative HHS ideas that have been developed as a result of a more open and accessible federal decision making process in collaboration between the public, private sector and the federal government.

Medicare Health Plan Enrollees Receive a Notice of Medicare Non-Coverage

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Medicare health plan enrollees receive a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare-covered skilled nursing facility (SNF), home health (HH), and comprehensive outpatient rehabilitation facility (CORF) services