What Is Medicare?
Medicare is health insurance for the following:
1. People age 65 or older
2. People under age 65 with certain disabilities
3. People of any age with End-Stage Renal Disease (ESRD) (permanent kidney ■■failure requiring dialysis or a kidney transplant)
The Different Parts of Medicare
The different parts of Medicare help cover specific services. Medicare has the following parts:
Medicare Part A (Hospital Insurance)
Helps cover inpatient care in hospitals
Helps cover
skilled nursing facility, hospice, and home health care
Medicare Part B (Medical Insurance)
Helps cover doctors’ services, outpatient care, and home health care
Helps cover some preventive services to help maintain your health and to keep
Certain illnesses from getting worse
Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO)
A health coverage option run by private insurance companies approved by and ■■under contract with Medicare
Includes Part A, Part B, and usually other coverage like prescription drugs
Medicare Part D (Medicare Prescription Drug Coverage)
A prescription drug option run by private insurance companies approved by and ■■under contract with Medicare
Helps cover the cost of prescription drugs
May help lower your prescription drug costs and help protect against higher costs in the future
Your Medicare Coverage Choices
With Medicare, you can choose how you get your health and prescription drug coverage. Below are brief descriptions of your coverage choices. Section 2 has more details about these choices and information to help you decide.
Original Medicare – Run by the Federal government
Provides your Part A and/or Part B coverage
You can go to any doctor or hospital that accepts Medicare
You can join a Medicare Prescription Drug Plan to add drug coverage.
You can buy a Medigap (Medicare Supplement Insurance) policy (sold by private insurance companies) to help fill the gaps in Part A and Part B.
Medicare Advantage Plans (like an HMO or PPO) Run by private insurance companies approved by and under contract with Medicare.Provides your Part A and Part B coverage but can charge different amounts for certain services. May offer extra coverage and prescription drug coverage, sometimes for an extra cost. Cost for items and services vary by plan.
If you want drug coverage, you must get it through your plan (in most cases).You don’t need, and you can’t use a Medigap policy with a Medicare Advantage Plan.
Other Medicare Health Plans
Plans that aren’t Medicare Advantage Plans but are still part of Medicare.Include Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
Most plans provide Part A and Part B coverage, and some also provide prescription drug coverage (Part D).
Note: You might also have health and/or prescription drug coverage from a former or current employer or union that could affect your choices.
MEDICARE ADVANTAGE CLAIMS
Medicare Advantage (MA) claims should be submitted directly to BCBSKS, which will report the status of such claims on its remittance advices. However, MA claims cannot and will not be processed or appealed pursuant to BCBSKS policies and procedures. For MA claims occurring under a form of coverage offered by a Blue Cross and Blue Shield Plan other than BCBSKS, such other Blue Plan is solely responsible for determining pricing and medical policy (as required by the Centers for Medicare & Medicaid Services (CMS)). A provider’s contracting status with CMS determines MA payment allowances. The provider may appeal MA claims only to the Blue Plan providing the MA coverage regardless of whether BCBSKS or another Blue Cross and Blue Shield Plan issued payment. The provider agrees to abide by the final determination resulting from the MA appeals process, which is established by CMS. The appeals policies and procedures of such other Blue Plans should be obtained from those Blue Plans directly.
