How much does Medicare part A cover after surgery/hospital stay?

[somarco]

This section might be of interest to marketers . . .

4. Third-Party Marketing Organizations

In the proposed rule, we discussed our concerns regarding third-party marketing organizations (TPMOs) as well as the reasons for those concerns. We also explained that, while we acknowledge that TPMOs can serve a role in helping a beneficiary find a plan that best meets the beneficiary's needs, additional regulatory oversight is required to protect Medicare beneficiaries from confusing and potentially misleading activities in this space and to ensure that Medicare health and drug plans are appropriately overseeing and maintaining responsibility for the entities that conduct marketing and, potentially, enrollment activities on the plans' behalf. To this end, CMS proposed several updates to various sections of parts 422 and 423, subpart V.

and this . . .

10. Marketing and Communications Requirements on MA and Part D Plans To Assist Their Enrollees (§§ 422.2260 and 423.2260, 422.2267 and 423.2267, 422.2274 and 423.2274)

CMS has seen an increase in beneficiary complaints associated with third-party marketing organizations (TPMOs) and has received feedback from beneficiary advocates and stakeholders concerned about the marketing practices of TPMOs who sell multiple MA and Part D products. In 2020, we received a total of 15,497 complaints related to marketing. In 2021, excluding December, the total was 39,617. We are unable to say that every one of the complaints is a result of TPMO marketing activities, but based on a targeted search, we do know that many are related to TPMO marketing. In addition, we have seen an increase in third party print and television ads, which appears to be corroborated by State partners. Through this final rule, we will address the concerns with TPMOs by means of the following three updates to the communications and marketing requirements under 42 CFR parts 422 and 423, subpart V: (1) We define TPMOs in the regulation at §§ 422.2260 and 423.2260 to remove any ambiguity associated with MA plans/Part D sponsors responsibilities for TPMO activities associated with the selling of MA and Part D plans; (2) we add a new disclaimer that will be required when TPMOs market MA plans/Part D products (§§ 422.2267(e) and 423.2267(e)); and (3) we update §§ 422.2274 and 423.2274 to require additional plan oversight requirements associated with TPMOs, in addition to what is already required under §§ 422.504(i) and 423.505(i) if the TPMO is a first tier, downstream or related entity (FDR).

 

[Bob L]

In 2020, we received a total of 15,497 complaints related to marketing. In 2021, excluding December, the total was 39,617.

I'd be willing to wager my next house payment that the vast majority of those 39,617 complaints were not against individual brokers who are unaffiliated with the big Joe Namath-type marketers.

 

[somarco]

Casting a wide net . . . and we suffer because fat cats messed it up for all of us

 

[MBSC]

WHY would a hospital agree to bill and collect on behalf of a non-affiliated provider (such as a surgeon)? If/when they collect, do they forward the collected amount to the provider?

Seems like a lot of bookkeeping on their part that is uncompensated.

And you are saying they routinely do this, including non-par providers?

When an MA member has a covered inpatient stay at an in-network hospital, the anesthesiologist bills the MA plan just like they bill original Medicare. The MA plan pays the provider 100% of the amount required under the Medicare Managed Care regulations with no patient cost sharing.

The surgeon and assistant surgeon bill the MA plan just like they bill original Medicare. The MA plan pays the providers the amounts required under the Managed Care regulations with no patient cost sharing.

The hospital bills facility charges to the MA plan just like they bill original Medicare. The MA applies the daily inpatient hospital copay as outlined in the plan documents. This is the only member responsibility for a covered in-network inpatient hospital stay.

The member may receive a consolidated EOB listing all of the above. That is just the plan pulling everything together for the member's convenience.

Do MA members occasionally receive bills from the physicians? Yes. The plan documents instruct the member to call the plan in these instances. The plan will straighten out the situation.

The copay for in-network outpatient hospital is also inclusive of physician services. However, additional copays like an MRI can also be applied.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 110.1.3 – Services for Which MA Plans Must Pay Non-contracted Providers and Suppliers

When an enrollee visits an in-network provider, even though that in-network provider may work with an out-of-network provider, then the enrollee is only responsible for in-network cost-sharing.

Section 170
MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described above.

Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

 

[straightnochaser]

When an MA member has a covered inpatient stay at an in-network hospital, the anesthesiologist bills the MA plan just like they bill original Medicare. The MA plan pays the provider 100% of the amount required under the Medicare Managed Care regulations with no patient cost sharing.

The surgeon and assistant surgeon bill the MA plan just like they bill original Medicare. The MA plan pays the providers the amounts required under the Managed Care regulations with no patient cost sharing.

The hospital bills facility charges to the MA plan just like they bill original Medicare. The MA applies the daily inpatient hospital copay as outlined in the plan documents. This is the only member responsibility for a covered in-network inpatient hospital stay.

The member may receive a consolidated EOB listing all of the above. That is just the plan pulling everything together for the member's convenience.

Do MA members occasionally receive bills from the physicians? Yes. The plan documents instruct the member to call the plan in these instances. The plan will straighten out the situation.

The copay for in-network outpatient hospital is also inclusive of physician services. However, additional copays like an MRI can also be applied.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 110.1.3 – Services for Which MA Plans Must Pay Non-contracted Providers and Suppliers

When an enrollee visits an in-network provider, even though that in-network provider may work with an out-of-network provider, then the enrollee is only responsible for in-network cost-sharing.

Section 170
MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described above.

Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

Marco learned something today!

 

[goillini52]

Marco learned something today!

I sure did.

 

[policywunk]

When an MA member has a covered inpatient stay at an in-network hospital, the anesthesiologist bills the MA plan just like they bill original Medicare. The MA plan pays the provider 100% of the amount required under the Medicare Managed Care regulations with no patient cost sharing.

The surgeon and assistant surgeon bill the MA plan just like they bill original Medicare. The MA plan pays the providers the amounts required under the Managed Care regulations with no patient cost sharing.

The hospital bills facility charges to the MA plan just like they bill original Medicare. The MA applies the daily inpatient hospital copay as outlined in the plan documents. This is the only member responsibility for a covered in-network inpatient hospital stay.

The member may receive a consolidated EOB listing all of the above. That is just the plan pulling everything together for the member's convenience.

Do MA members occasionally receive bills from the physicians? Yes. The plan documents instruct the member to call the plan in these instances. The plan will straighten out the situation.

The copay for in-network outpatient hospital is also inclusive of physician services. However, additional copays like an MRI can also be applied.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 110.1.3 – Services for Which MA Plans Must Pay Non-contracted Providers and Suppliers

When an enrollee visits an in-network provider, even though that in-network provider may work with an out-of-network provider, then the enrollee is only responsible for in-network cost-sharing.

Section 170
MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described above.

Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

That is all just insurance contract/plan document gobbledygook -you got any real proof of this like an EOB or hospital bill ? Just kidding.Thanks for posting this.This is also what it says in the MA plan EOC in more plain English so even consumers can understand it.