Chapter 5
Patient Eligibility

5.1 Entitlement

a. Persons 65 and older

Generally, people age 65 and over can get premium-free Medicare Part A benefits, based on their own or their spouse's employment. (Premium-free means there are no monthly premiums. Most people do not pay premiums for Medicare Part A). Persons age 65 and over are eligible to receive Medicare Part A when:

Generally, if either the beneficiary or their spouse worked for 10 years, they will be able to get premium-free Medicare Part A benefits.

Any person who can get premium-free Medicare Part A benefits based on work as described above can enroll and receive Part B benefits, when they pay the monthly Part B premium. Some individuals pay more than the basic premium because they enrolled late or they withdrew from the program and later re-enrolled. Most United States citizens, age 65 or over, can enroll in Medicare Part B.

For Medicare Part B benefits, the beneficiary is responsible for a monthly premium of $45.50 in 1999. In addition, a beneficiary is required to meet a $100.00 annual deductible under Part B. The deductible is applied based on the calendar year in which the services were rendered. Medicare Part B generally pays 80% of the approved charges, leaving the other 20% (known as coinsurance) payable by the patient or their coinsurer.

Medicare Part B benefits cover a wide range of services, such as: physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, supplies, clinical laboratory services, home healthcare, outpatient hospital treatment, and ambulance services.

When an individual becomes entitled to Medicare he/she receives a Health Insurance Card which shows his/her name, sex, Medicare number and the effective dates of entitlement to hospital (Part A) insurance and medical (Part B) insurance. Entitlement begins the first day of the month and ends the last day of the month, with the exception of death.

The Medicare numbers issued by the Health Care Financing Administration are usually Social Security numbers with letter (alpha) or letter/number (alpha/numeric) suffixes.

When a Medicare beneficiary first visits your office, it's a good idea to request a copy of the Medicare card for your files. For a husband and wife, obtain a copy of both cards since the numbers will be different for each. The majority of Medicare patients will be those for whom eligibility is based on Social Security benefits. HGSAdministrators will process the Part B claims for most of these patients. Ask your patients for any other insurance cards they may have.

NOTE: The Medicare identification number may be different than the patient's Social Security number. This is true, for example, when a dependent qualifies for Medicare based on a family member's employment record. Be sure to use the patient's name exactly as it appears on their Medicare card when filing claims to Medicare.

b. Beneficiary Right to Itemized Statement for Medicare Items and Services

b.1 Requirements of the Law


Effective January 1, 1999, section 4311(b) of the Balanced Budget Act of 1997 gives beneficiaries the right to submit a written request for an itemized statement from their provider/supplier for any Medicare item or service. The law requires that providers/suppliers furnish the itemized statement within 30 days of the request, or they may be subject to a civil monetary penalty of $100 for each unfulfilled request. If an itemized statement is received, the beneficiary may request the Medicare contractor to review specific issues (i.e., services not provided, billing irregularities, and appropriate measures to recover any amount inappropriately paid).


Medicare carriers currently issue beneficiaries an Explanation of Medicare Benefits (EOMB) or a Medicare Summary Notice (MSN). Information that may be listed include the following: date(s) of services, a description of services provided, number of services provided, benefit days used, non-covered charges, deductible and coinsurance, beneficiary liability, amount charged, claim number, name of provider/supplier submitting the claim, claim total paid by Medicare and referring physician (if applicable). Other information that may be included are deductibles, appeal rights or notices, and explanatory notes and general information regarding the specific claim.


Effective April 1, 1999, these notices will begin to include the following statement: "You have a right to request an itemized statement which details each Medicare item or service which you have received from your physician, hospital or any other health supplier or health professional.


b.2 Guidance Concerning the Format and Substance of the Itemized Statement


Included below are suggestions regarding the types of information that might be helpful for the beneficiary to receive on an itemized statement. We hope this information will enable the beneficiary to reconcile the itemized statement with the Medicare notice. These are recommendations only. Since most providers/suppliers have established an itemized billing system for internal accounting procedures and billing of other payers, the furnishing of an itemized statement should not pose a significant additional burden. However, some providers/suppliers may not regularly create or furnish hard copy itemized statements and may wish to reexamine their internal billing and tracking process to ensure that it has the capability to comply with this new requirement. Providers/suppliers should not charge beneficiaries for the itemized statement.

b.3 Itemized Statement Recommendations:

If the claim has been adjudicated by Medicare, additional information that can be included on the itemized statement are:

The statement should also include a name and a telephone number for the beneficiary to call if there are further questions.

b.4 Reconciliation of the Itemized Statement with the MSN/EOMB


After receiving an itemized statement, beneficiaries may attempt to reconcile it with the MSN or EOMB. In situations where there are questions, especially involving some services and payment methods, providers/suppliers are requested to assist beneficiaries in understanding any differences between the two documents.


In addition, although Medicare contractor customer service representatives may not have a copy of the itemized statement, they will also answer any beneficiary inquiries regarding the EOMB/MSN and attempt to reconcile it with the itemized statement. Where appropriate, customer service representatives will attempt to resolve any questions by generally explaining applicable Medicare reimbursement rules, (prospective payment systems, revenue codes, bundling, interim rates, HCPC/CPT codes, etc.).


b.5 Beneficiary Right to Request Review of the Itemized Statement


Beneficiaries may submit a written request to their Medicare contractor for a review of a claim based on information they provide from their itemized statement. The request should identify the specific items or services that the beneficiary believes were not provided as claimed, or any other billing irregularity (including duplicate billing). A review will be conducted into the matter by the Medicare contractor and providers/suppliers may be requested to assist in the review of the itemized statement/Medicare claim. Contractors will review and take appropriate actions to resolve the complaint.

c. Disability

Additionally, a person under 65 may also receive premium-free Medicare Part A benefits if he/she has been receiving disability benefits under Social Security or the Railroad Retirement Board for more than 24 months.

A person who is entitled to Social Security, Railroad Retirement, or equivalent federal government benefits on the basis of disability is automatically entitled to hospital insurance (Part A), and is considered enrolled for Part B unless coverage is refused. This entitlement begins after the individual has been disabled for a total of 29 months (five month waiting period plus 24 months of entitlement). This type of entitlement is also available to a disabled widow, widower or child of a deceased, disabled or retired worker. If an individual recovers from a disability, Medicare entitlement ends in the month following notification of the disability termination.

d. End Stage Renal Disease

A person with end stage renal disease may be any age, receiving dialysis or renal transplantation. An individual is eligible for Part A (and is considered enrolled for Part B unless coverage was refused) if he/she:

Entitlement usually begins three months after a course of renal dialysis begins; however, it may begin sooner if the individual receives a transplant or participates in a self-dialysis training program during the waiting period. Coverage ends on the last day of the 12th month after the course of dialysis is discontinued, or the last day of the 36th month after a kidney transplant.

5.2 Special Situations

a. Railroad Retirees

Claims for Medicare patients who are entitled to coverage based on Railroad Retirement benefits are handled by the United Health Care Insurance Company. 

Railroad Retirees Health Insurance Claim Numbers can be easily identified because the numbers begins with letters such as A, MA, WA, or WD. If the patient is entitled to Medicare based on Railroad Retirement benefits, send your claims and inquiries to:

The United Health Care Insurance Company
Railroad Retirees Benefits Medicare Claim Office
P.O. Box 10066
Augusta, GA 30999 0001
(706) 855-1386

b. United Mine Workers of America (UMWA)

Some Medicare patients are members of the UMWA. Claims and inquiries for these patients must be processed by the UMWA. Send these claims to:

UMWA Health and Retirement Funds
Box 9224
Van Nuys, CA 91409
ATTN: Medicare Payments

These beneficiaries probably have an identification card showing UMWA retiree coverage.

c. Medicaid

Medicaid is a health insurance program jointly funded by the states and the federal government, that provides medical aid for people who are unable to finance their own medical expenses. If a patient is eligible for both Medicare and Medicaid, submit your claim to Medicare first.

If the patient does have Medicaid coverage, you are required to accept assignment on the Medicare claim.

5.3 Medicare + Choice
When Congress passed the Balanced Budget Act of 1997, it included changes to the Medicare program. The new law includes a section called Medicare + Choice, which provides new health plan options to Medicare beneficiaries effective January 1, 1999. This new provision may be referred to as Medicare ďPart CĒ by some beneficiaries. All of the plans under Medicare + Choice provide the basic Medicare benefits currently available. One option will continue to be the Original Medicare plan or the Original Medicare Plan with a supplemental (Medigap) policy. Or, beneficiaries who are eligible for both Part A and Part B may choose to have covered items and services furnished by one of the other Medicare + Choice health plan options available in their area. The Health Care Financing Administration (HCFA) determines the annual deductible amount for Original Medicare only. All other Medicare + Choice plans can set their own deductible amounts or choose not to charge a deductible. They also decide whether to charge a monthly premium in addition to the Medicare Part B premium.
Medicare beneficiaries do not have to change to a different health plan. If a beneficiary is happy with the Medicare plan they now have, they do not have to change to another Medicare + Choice plan. No matter which Medicare + Choice health plan option a beneficiary chooses to join or stay in, they are still in the Medicare program.

a. Health Maintenance Organization (HMO)
A medicare beneficiary may choose to enroll in a qualified organization which has entered into a federal contract to participate as a Medicare + Choice Health Maintenance Organization (HMO). An HMO is defined, for Medicare purposes, as a public or private organization which provides, either directly or through arrangements with others, a comprehensive range of health services to enrolled members who live within a specified service area. An HMOís service area is
defined as the geographic area in which the HMO offers a full range of services to its members. Payment is based on a predetermined periodic rate, or periodic per capita rate, without regard to the frequency or extent of covered services furnished to any particular member. The HMO must also meet statutory requirements.

A Medicare HMO patient must have all services rendered by the planís network of professional health care providers. These plans may assign a primary care physician, known as a ďgatekeeperĒ, who decides whether or not the patient may be referred to a specialist. Most HMOs require the patient to pay a copayment for each service rendered.

b. Health Maintenance Organization (HMO) with Point of Service (POS) Option
An HMO with a Point of Service (POS) Option allows the Medicare patient to use health care professionals and hospitals outside of the planís network for an additional charge.

c. Preferred Provider Organization (PPO)
A Preferred Provider Organization (PPO) is a plan that buys health care services from a select group of participating providers. Most PPOs will require the patient to pay a small copayment for each service rendered. A PPO is similar to the HMO with a POS option in that patients are encouraged to use the planís network of health care professionals and hospitals by the use of rewards or discounts. However, patients may use health care professionals and hospitals outside of the planís network for an additional out-of-pocket cost. A PPO plan is subject to quality assurance rules.

d. Provider Sponsored Organization (PSO)
A Provider Sponsored Organization (PSO) is a managed care plan that works like an HMO except that the affiliated physicians and hospitals operate the plan. The majority of the services a patient receives must be provided directly by the affiliated physicians and hospitals. The plan may require the patient to pay a small copayment amount for each service rendered. A PSO plan is likely to appear in rural areas where HMOs are not available. A PSO plan is subject to quality assurance rules.

e. Private Fee-for-Service
A Private Fee-for-Service plan is run by a private insurance company that accepts Medicare beneficiaries. Medicare pays the plan a premium for Medicare covered services. Patients may go to any doctor or hospital that has been approved by the plan to provide covered services and agrees to the terms and conditions set by the plan. The patient may be required to pay a copayment amount for each service rendered. Under this plan, the insurance company, not the Health Care Financing Administration (HCFA) decides how much to reimburse for the service rendered. Providers in this plan can charge the patient up to 15 percent more than the planís rate. The planís rate could be higher or lower than the Medicare Fee Schedule rate. Patients are still protected by the 15 percent balance billing ceiling that applies to
Original Medicare. If a Medicare patient receives emergency or urgently needed care from a noncontract provider, they cannot be charged for balance billing. The plan may or may not provide extra benefits that Original Medicare does not cover. These plans do not have to meet certain quality standards that other HCFA plans must meet.

f. Medicare Medical Savings Account (MSA)
A Medicare Medical Savings Account (MSA) is a test program with a limited national enrollment of 390,000 beneficiaries. The plan is a special type of savings account through a private insurance company that is used to pay medical bills. The beneficiary is responsible for opening the MSA, but only the Health Care Financing Administration (HCFA) can deposit money into the account. HCFA uses capitation rates to determine the amount each beneficiary should receive for the year. From this amount, HCFA pays the premium set by the MSA plan and then deposits the remainder into the MSA. Any money not used at the end of the year stays in the account and accrues interest. Money taken from the account for payment of medical expenses is not taxed. However, if a beneficiary uses money from the MSA for something other than medical expenses, that amount will be considered as additional income and taxed by the Internal Revenue Services (IRS). At the beginning of a new year, HCFA deposits more money into the account. Depending on the premium and deductible amounts of the MSA plan chosen by the beneficiary, it may take a period of time for the beneficiary to accumulate enough money in their MSA to cover their medical expenses. The money in the MSA can be used by the Medicare beneficiary to pay their annual deductible amount which is set by the MSA plan and can be as high as $6,000, and any covered Medicare
services. After their annual deductible is met, the MSA plan insurer will pay for covered Medicare services and the money in the MSA can be used to pay for services not covered under Medicare (i.e., dentures, hearing aids, etc.)

g. Religious Fraternal Benefits Plan (RFB)
This plan must meet the Health Care Financing Administrationís (HCFA) definition of a managed care plan and is offered only to members of the church, convention or affiliated group (i.e., Mennonite Mutual Aid Society). The plan agrees to enroll all members without regard to the status of their health and to provide at least the same level of health coverage to individuals not entitled to Medicare benefits who are members of their church.

5.4 Hospice Care

Beneficiaries who have a terminal illness with a life expectancy of six months or less have the option of electing hospice coverage instead of the standard Medicare coverage. Effective August 5, 1997, hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the hospice patient's lifetime.

Even though a beneficiary elects hospice coverage, he or she may designate and use a private attending physician, who is not employed by the hospice for professional services in addition to the services of hospice-employed physicians.

A private attending physician means a physician who:

It is the responsibility of the hospice to send a Notice of Admission (NOA) form to both the Medicare Part A Intermediary and the Medicare Part B Carrier. The NOA form identifies the hospice, the private attending physician, and the terminal diagnosis.

Only Medicare approved hospices are covered under this provision. The hospice bills the Part A Intermediary for hospice physician services provided by its physicians.

a. Private Attending Physician Services Billable to Medicare Part B

The professional services of a private attending physician that are reasonable and necessary for the treatment and management of a hospice patient's terminal illness are not considered hospice services. Such services may be billed to the Part B carrier provided they are furnished by a physician who is not under a payment arrangement with the hospice.

Medicare Part B claims for services rendered within the hospice elected period of coverage will be processed routinely under the following situations when:

b. Reporting Guidelines

To receive Medicare Part B reimbursement for eligible services rendered to hospice beneficiaries, private attending physicians should report the following information in the narrative portion of an electronic claim or in block 19 of the HCFA 1500 (12-90) claim form:

b.1 Services Not Payable by Medicare Part B

Claims will be denied by Medicare Part B for beneficiaries who have services furnished within the hospice elected period under the following situations:

5.5 Common Working File

Common working file (CWF) is a HCFA query/reply system which determines a beneficiary's deductible and entitlement status. All beneficiaries are assigned a host. The host is responsible for supplying the intermediaries and carriers with a beneficiary's deductible and entitlement status. In a common working file environment, the intermediaries and carriers are called satellites. The host is responsible for maintaining all beneficiary and claims history information for each beneficiary assigned to that particular host.

Note: The Health Care Financing Administration (HCFA) is the central processor of all beneficiary information.