Medicare is the federal health insurance program administered by the Centers for Medicare & Medicaid Services for Americans aged 65 and older and for younger adults with permanent disabilities.
Rural America has a large percentage of elderly residents so any changes in Medicare policy would have implications on rural people and communities. Medicare is often a part of discussions about how to limit the growth in federal spending and limit health care costs. It is a great challenge to provide increasingly expensive medical care to an aging population as well as keep the program financially secure for future generations.
Source
The Basics: Medicare, National Health Policy Forum, 2011
Related Guides
Frequently Asked Questions
Tools
2011 CMS Statistics
Web site
Contains annual booklets of information about health expenditures and the Centers for Medicare & Medicaid Services' (CMS) programs. Published in June of each year. Covers 2003 through the most currently available complete calendar year.
2012 Medicare Health and Drug Plans by State
Web site
Presents a page for each state containing fast facts, important dates, number of plans, and data regarding plan costs and coverage.
2012 Medicare Physician Payment Rates
Web site
Presents the Medicare Physician Payment rates. Includes updates and changes in legislation and rules. Includes payment rates for nursing facilities. Lists the physician fee schedule updates for the nursing facility codes.
2012 Physician Fee Schedule Overview
Web site
Presents an overview of the physician fee schedule. Includes updates on the final rule as well as resources to download.
Benefit Eligibility Screening Tool (BEST)
Web site
Assists people in finding out what benefits they are eligible for from any of the programs Social Security administers.
BenefitsCheckUp
Web site
Helps Medicare beneficiaries learn about and enroll in government benefits, including Medicare Part D, the Supplemental Nutrition Assistance Program, and Eldercare Assistance.
CMS Contacts
Web site
Provides access to the CMS.gov Contacts Database. Allows for searching by state, region, contact type, and organization.
CMS Recovery Audit Program
Web site
Provides information on the Recovery Audit program, to reduce Medicare improper payments through detection and collection of overpayments, the identification of underpayments and the implementation of actions to prevent future improper payments.
CMS Regional Office Rural Health Coordinators
Web site
Contains a list of CMS regional rural health coordinators who provide technical, policy, and operational assistance on rural health issues.
CMS Regional Offices
Web site
Provides contact information for the CMS Regional Representatives serving 10 regions across the United States.
Find Shortage Areas: HPSAs Eligible for the Medicare Physician Bonus Payment
Web site
Determines whether or not a HPSA address is eligible for the Medicare HPSA Physician Bonus. Also called The Geographic Eligibility Advisor for Medicare HPSA Bonus Payments.
Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs)
Web site
Presents information and resources concerning Medicare bonus payments for physicians who provide services to Medicare beneficiaries in areas that are designated as Physician Scarcity Areas (PSAs) and Geographic Health Professional Shortage Areas (HPSAs). Includes lists of eligible zip codes for receiving the bonus payments.
Health Reform and Medicare: Overview of Key Provisions
Tutorial
Presents an audio-visual tutorial that describes provisions of the Affordable Care Act (ACA) that affect the many Medicare programs.
KaiserEDU
Web site
Presents resource lists and tutorials on health policy and public health topics, with links to publications, data, and organizations. Topics covered include Medicare, Medicaid, SCHIP, the uninsured, quality of care, and more. Designed for health policy students and faculty.
Medicare & Medicaid Statistical Supplement
Web site
Presents annual Medicare and Medicaid Statistical Supplement reports from 2001 to the present. Provides detailed statistical information on Medicare, Medicaid, and other Centers for Medicare & Medicaid Services (CMS) programs.
Medicare Certified Rural Health Clinics
Web site
Provides a list of all RHCs in each of the 50 states. Includes provider number, name, address, city-state-zip, phone number, and county.
Medicare Learning Network
Web site
Provides official CMS provider products designed to promote national consistency of Medicare provider information. Developed for CMS initiatives including Medicare fee-for-service providers. Contains publications and resources for the health care professional.
Medicare State Health Facts
Web site
Provides current data about states' aged and disabled Medicare beneficiaries, Medicare Prescription Drug Plans, and Medicare Advantage such as enrollment, demographics (such as age, gender, race/ethnicity), spending, other sources of health coverage, managed care participation, and use of services.
Medicare.gov (English)
Database
Provides a searchable website on a host of Medicare related resources: The four parts of Medicare, Medicare basics, applying online for Medicare, enrolling in a prescription drug plan, ordering a Medicare replacement card, finding a doctor, and comparing hospitals and nursing homes.
MedlinePlus: Medicare
Web site
Presents links to resources, tools and news related to Medicare.
Research Data Assistance Center
Research instrument
A Centers for Medicare and Medicaid Services (CMS) contractor that provides free assistance to academic, government, and non-profit researchers interested in using Medicare and/or Medicaid data for their research.
Resources on People Dually Eligible for Medicaid and Medicare
Web site
Presents resources which examine the dual eligible population, their health care needs and spending, and ongoing efforts to coordinate care across the two programs.
Rural Health Research: Medicare
Web site
Provides summaries of current and completed rural health research projects and related publications addressing the topic of Medicare, produced by the Office of Rural Health Policy's funded rural health research centers.
Social Security Online
Web site
Identifies programs and online services of the Social Security Office, including information on qualifying and applying online for disability and survivorship benefits.
State Survey Agency Directory
Web site
Contains a directory of state agencies that handle survey and certification of certain health care facilities for compliance with the Medicare health and safety standards. Updated quarterly.
Talking About Medicare: Your Guide to Understanding the Program, 2012
Web site
Provides answers to some basic questions related to Medicare coverage. Includes a state-by-state list of key agencies that can answer specific questions about Medicare, Medicaid, supplemental health insurance, the Medicare prescription drug benefit, and long-term care.
Maps & Map Collections
Medicare Mortality Rates
Interactive
Geographic coverage: United States
Printable map that shows the ASR-adjusted percentage of deaths among Medicare enrollees by hospital referral region nationwide. Data source: Dartmouth Atlas, 2007.
Date: 2012
Medicare Reimbursement
Interactive
Geographic coverage: United States
Printable map that shows the total Medicare reimbursement per enrollee (Part A & B) by hospital referral region nationwide. Data source: Dartmouth Atlas, 2006.
Date: 2006
Selected Medical Discharge Rates
Interactive
Geographic coverage: United States
Printable map that shows all medical discharges per 1,000 Medicare enrollees by hospital referral region nationwide. Data source: Dartmouth Atlas, 2005.
Date: 2007
Regulations, Forms & Other Useful Documents
2011 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds
Author(s): Timothy F. Geithner, Hilda L. Solis, Kathleen Sebelius, Michael J. Astrue, Charles P. Blahous, Robert D. Reischauer, Donald M. Berwick
Presents the report to Congress on the financial and actuarial status of Medicare's Health Insurance (HI) and Supplementary Medical Insurance (SMI) trust funds. Includes provisions of the new Affordable Care Act (ACA) that affect Medicare and rural areas.
Date: 05 / 2011
2011 Report to the Secretary: Rural Health and Human Services Issues
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
Report to the Secretary of the U.S. Department of Health and Human Services. Includes chapters focused on rural childhood obesity, place-based initiatives for rural early childhood development, and rural implications of accountable care organizations and payment bundling. Includes recommendations to address these issues. Includes appendices regarding June 2010 and September 2010 site visits.
Date: 03 / 2011
Acute Care Hospital Inpatient Prospective Payment System: Payment System Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides general information about the Acute Inpatient Prospective Payment System (IPPS) including IPPS payment rates and how IPPS payment rates are set.
Date: 02 / 2012
Basics: Medicare
Sponsoring organization: National Health Policy Forum
Highlights what Medicare is, it's parts, who is eligible, and services covered.
Date: 01 / 2011
Comparison of Rural Hospitals with Special Medicare Payment Provisions to Urban and Rural Hospitals Paid Under Prospective Payment (Final Report)
Author(s): G. Mark Holmes, George H. Pink, Sarah A. Friedman, Hilda A. Howard
Sponsoring organization: North Carolina Rural Health Research and Policy Analysis Center
Compares the financial performance and condition of rural hospitals with special Medicare payment provisions to urban and rural hospitals paid under prospective payment (U-PPS and R-PPS hospitals, respectively).
Date: 08 / 2010
Critical Access Hospital: Rural Health Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information about Critical Access Hospital providers, designations, and payments.
Date: 01 / 2012
Data Book: Health Care Spending and the Medicare Program, 2011
Sponsoring organization: Medicare Payment Advisory Commission
Provides data, including some rural-specific statistics, on various aspects of the Medicare program. Covers beneficiary demographics, quality and access, national health care spending, and data for specific provider settings. Includes sections on Medicare Advantage and prescription drug coverage for Medicare beneficiaries.
Date: 06 / 2011
Fact Sheet: Medicare Advantage
Sponsoring organization: Kaiser Family Foundation
Provides an overview of the Medicare Advantage program. Describes program changes made by the new health reform law in plan participation and beneficiary enrollment, presents data on benefits and premiums, and explains changes in Medicare payments to participating plans.
Date: 11 / 2011
Fact Sheet: Medicare and Nonelderly People With Disabilities
Sponsoring organization: Kaiser Family Foundation
Presents an overview of Medicare's role in providing health care to 8 million people under age 65 who qualify for coverage due to a permanent disability.
Date: 09 / 2010
Fact Sheet: Medicare at a Glance
Sponsoring organization: Kaiser Family Foundation
Provides an overview of the Medicare program, including how it is financed, who is eligible, and what benefits are covered under the program. Describes supplemental health insurance, and data on Medicare expenditures and financing.
Date: 11 / 2011
Fact Sheet: Medicare Shared Savings Program and Rural Providers
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides an overview of Accountable Care Organizations (ACOs) for rural providers. Discusses rules to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients.
Date: 10 / 2011
Fact Sheet: Medicare Spending and Financing
Sponsoring organization: Kaiser Family Foundation
Provides an overview of spending on the Medicare program, how the program is financed. Includes data on Medicare financing and incorporates reductions in the rate of growth of Medicare spending attributable to the 2010 health reform law.
Date: 09 / 2011
FAQs: Versions 5010 and D.O Transition Basics
Sponsoring organization: Centers for Medicare and Medicaid Services
Answers frequently asked questions regarding the transition to Version 5010 and D.O software. Version 5010 pertains to standards for electronic administrative transactions. D.O is the version of the National Council for Prescription Drug (NCPDP) standards for pharmacy transactions that replaces version 5.1.
Date: 07 / 2011
Focus on Health Reform: Summary of Key Changes to Medicare in 2010 Health Reform Law
Sponsoring organization: Kaiser Family Foundation
Provides a detailed look at the improvements in Medicare benefits, changes to payments for providers and Medicare Advantage plans, various demonstration projects, and other Medicare provisions in the law.
Date: 2010
Geographic Adjustment in Medicare Payment Phase I: Improving Accuracy, Second Edition
Sponsoring organization: Institute of Medicine
Report brief that expands on recommendations made in an earlier IOM report for improving how the Medicare program calculates geographic practice cost indexes resulting in payments to hospitals, physicians, and other clinical practitioners according to the geographic locations.
Date: 06 / 2011
Guide to Medicare Preventive Services
Sponsoring organization: U.S. Department of Health and Human Services
Includes coverage, coding, billing, and reimbursement information for each of the
preventive benefits covered by Medicare. Includes information for Rural Health Clinics and FQHCs.
Date: 03 / 2011
Health Centers and Health Care Reform: Medicare Reimbursement for Health Centers
Sponsoring organization: National Association of Community Health Centers
Examines the changes to Federally Qualified Health Center (FQHC) services and the associated Medicare reimbursements as dictated in the Patient Protection and Affordable Care Act (PPACA).
Date: 04 / 2010
Health Centers and Health Care Reform: Public Insurance Programs
Sponsoring organization: National Association of Community Health Centers
Describes the expansion of Medicaid, the expansion of Medicare reimbursement rates, and the maintenance of the Children's Health Insurance Program (CHIP) income eligibility levels as dictated in the Patient Protection and Affordable Care Act (PPACA).
Date: 04 / 2010
High Performance Accountable Care: Building on Success and Learning from Experience
Author(s): Stuart Guterman, Stephen C. Schoenbaum, Karen Davis, et al.
Sponsoring organization: Commonwealth Fund
Describes accountable care organizations (ACOs) and the Medicare Shared Savings Program, a provision of the Affordable Care Act (ACA). Provides recommendations for ensuring the successful implementation and spread of ACOs to achieve the goals of a high performance health system.
Date: 04 / 2011
Impacts of the Medicare Modernization Act on Rural Health Systems and Beneficiaries
Author(s): Keith Mueller, Andrew Coburn, Charles Fluharty, A. Clinton MacKinney, Timothy McBride, Rebecca Slifkin, Mary Wakefield
Sponsoring organization: Rural Policy Research Institute Rural Health Panel
Offers an analysis of rural-pertinent provisions of the Medicare Modernization Act of 2003. Summarizes legislative and regulatory provisions of special significance to rural beneficiaries and health care systems. Includes Panel analysis of all provisions identified by the Panel as important to rural interests.
Date: 02 / 2005
Innovators' Guide to Navigating Medicare
Sponsoring organization: Centers for Medicare and Medicaid Services
Discusses processes used to determine coverage, coding, and payment for new technologies under the Medicare fee-for-service program. Guide is intended as a general summary.
Date: 2010
Low-Income & Rural Beneficiaries with Medigap Coverage, 2009
Sponsoring organization: AHIP Center for Policy and Research
Data from the 2009 Medicare Current Beneficiary Survey (MCBS) shows that Medigap is important to low and moderate-income beneficiaries, especially those living in rural areas.
Date: 09 / 2011
Low-Income & Rural Beneficiaries with Medigap Coverage, 2010
Sponsoring organization: AHIP Center for Policy and Research
Data from the Medicare Current Beneficiary Survey (MCBS) show that Medicare Advantage plans, Medicare’s private comprehensive health plans, continue to be a vital source of coverage for low-income and minority beneficiaries in 2010.
Date: 05 / 2012
Medicare & You: 2012
Sponsoring organization: Centers for Medicare and Medicaid Services
Highlights what's new, what's covered, health plans, prescription drug plans, and consumer rights.
Date: 12 / 2011
Medicare Advantage in Rural Areas
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
Presents a chapter from the 2007 Report to the Secretary: Rural Health and Human Service Issues. Addresses Medicare Advantage (MA), a program that provides health care benefits for elderly Americans through private insurance companies, and the impact that MA may have on rural beneficiaries and providers.
Date: 01 / 2007
Medicare Advantage Plans in Rural America
Author(s): Andrew F. Coburn, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
Sponsoring organization: Rural Policy Research Institute Rural Health Panel
Identifies key policy issues and questions concerning the impact of Medicare
Advantage (MA) in rural areas.
Date: 10 / 2007
Medicare and Home Health Care
Sponsoring organization: Centers for Medicare and Medicaid Services
Explains how to find home health agencies, the Medicare Home Health Benefit, what Medicare covers, and where to get help with questions.
Date: 05 / 2010
Medicare and Medicaid Programs; Electronic Health Record Incentive Program (Final Rule)
Sponsoring organization: Centers for Medicare and Medicaid Services
Includes the final rule which implements the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5). This ruling provides incentive payments to eligible professionals, hospitals, and critical access hospitals (CAHs) participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR) technology.
Date: 07 / 2010
Medicare and Medicaid Programs; Electronic Health Record Incentive Program: Stage 2
Sponsoring organization: Centers for Medicare and Medicaid Services
Federal Register edition describes the proposed rule, which specifies Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments.
Date: 03 / 2012
Medicare Beneficiary Access to Primary Care Physicians – Better in Rural, but Still Worrisome (Policy Brief)
Author(s): A. Clinton MacKinney, Liyan Xu, Keith J. Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Presents results from a national physician survey used to assess U.S. primary care physician and general surgeon willingness to accept Medicare patients and physician-reported reasons for not accepting Medicare patients.
Date: 01 / 2011
Medicare Beneficiary Quality Improvement Project (MBQIP)
Sponsoring organization: Health Resources and Services Administration
Discusses the goal of the Flex Medicare Beneficiary Quality Improvement Project (MBQIP), which is to improve rural quality care access for Medicare beneficiaries served by critical access hospitals (CAHs).
Date: 05 / 2011
Medicare Billing Information for Rural Providers and Suppliers
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides Medicare billing charts and information on where to submit claims for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), Skilled Nursing Facilities, Home Health Agencies, Critical Access Hospitals, and Swing Bed services.
Date: 09 / 2011
Medicare Chartbook, 2010
Sponsoring organization: Kaiser Family Foundation
Provides the most recent and reliable data available about the Medicare program and the 47 million seniors and younger people with disabilities who get health insurance coverage through the program. Includes both rural and urban data.
Date: 11 / 2010
Medicare Dependent Hospital: Rural Health Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information about Medicare Dependent Hospitals (MDH), including classification criteria, MDH payments, and resources.
Date: 11 / 2011
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
Sponsoring organization: U.S. Government Printing Office
Provides the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that passed by both Houses, H.R.
Date: 2008
Medicare Physician Fee Schedule: Payment System Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides general information about the Medicare Physician Fee Schedule (MPFS) including payment rates and MPFS payment rates formula.
Date: 12 / 2011
Medicare Physician Guide
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information about Medicare program including enrollment, reimbursement, payment policies, evaluation and management services, protecting the Medicare Trust Fund, and inquiries, overpayments and fee-for-service appeals.
Date: 05 / 2011
Medicare Physician Payment Policy and the Rural Perspective (Final Report)
Author(s): A. Clinton MacKinney, Keith J. Mueller, Timothy D. McBride
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Examines the effects of Medicare payment changes on rural physician practice revenue.
Date: 11 / 2008
Medicare Physician Quality Reporting Initiative: Implications for Rural Physicians (Final Report)
Author(s): Alycia Infante, Michael Meit, Elizabeth Hargrave
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Discusses the impact of rurality on office-based physicians' participation in the 2007 Physician Quality Reporting Initiative (PQRI), a voluntary pay-for-reporting program in Medicare.
Date: 08 / 2010
Medicare Physician Quality Reporting Initiative: Implications for Rural Physicians (Policy Brief)
Author(s): Alycia Infante, Michael Meit, Elizabeth Hargrave
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Explores the implementation and design of a P4R program, the Physician Quality
Reporting Initiative (PQRI), in order to identify the implications for rural physicians.
Date: 08 / 2010
Medicare Shared Savings Program: Accountable Care Organizations, Final Rule
Sponsoring organization: American Academy of Family Physicians
Summarizes segments of the rule on Medicare Accountable Care Organizations (ACOs) as they affect family practitioners in small and medium-sized practices, including Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs).
Date: 11 / 2011
Medicare's Role For Dual Eligible Beneficiaries
Author(s): Gretchen Jacobson, Tricia Neuman, Anthony Damico
Sponsoring organization: Kaiser Family Foundation
Examines Medicare spending for beneficiaries who are eligible for both Medicare and Medicaid. Describes the characteristics of those with the relatively high and low Medicare costs and includes state-specific data on the share of Medicare beneficiaries who are dual-eligibles.
Date: 04 / 2012
Medicare: A Primer
Sponsoring organization: Kaiser Family Foundation
Covers what is Medicare and who is eligible, characteristics, covered benefits, how it's financed, the Medicare Advantage program, and the Medicare drug benefit.
Date: 04 / 2010
Medicare’s Accountable Care Organization Regulations: How Will Medicare Beneficiaries who Reside in Medically Underserved Communities Fare?
Author(s): Sara Rosenbaum, Peter Shin
Sponsoring organization: George Washington University Department of Health Policy
Examines impact of ACO rule on medically underserved areas.
Date: 04 / 2011
MedPAC A Data Book: Health Care Spending and the Medicare Program, 2011
Sponsoring organization: Medicare Payment Advisory Commission
Provides data, including some rural-specific statistics, on various aspects of the Medicare program. Covers beneficiary demographics, quality and access, national health care spending, acute inpatient services, ambulatory and post-acute care, prescription drugs, and Medicare Advantage.
Date: 06 / 2011
MedPAC Report to Congress: Aligning Incentives in Medicare, June 2010
Sponsoring organization: Medicare Payment Advisory Commission
Focuses on how incentives in the Medicare program can be leveraged to promote quality of care and efficient use of resources - key elements of a high-value health care delivery system.
Date: 06 / 2010
MedPAC Report to Congress: Regional Variation in Service Use, January 2011
Sponsoring organization: Medicare Payment Advisory Commission
Presents data on the difference between regional variation in Medicare spending and regional variation in the use of Medicare-covered services. Data used was adjusted due to differences in small rural hospital and critical access hospital Medicare payment rates.
Date: 01 / 2011
MedPAC Report to the Congress: Medicare and the Health Care Delivery System
Sponsoring organization: Medicare Payment Advisory Commission
Includes chapters on Medicare payment accuracy, technical assistance, fee-for-service, care coordination, FQHC's, and private-sector payment rates.
Date: 06 / 2011
MedPAC Report to the Congress: Medicare Payment Policy, 2012
Sponsoring organization: Medicare Payment Advisory Commission
Annual review of Medicare payment policies, with recommendations to Congress. Discussions of rural aspects of Medicare payment policies are included throughout the report.
Date: 03 / 2012
MedPAC Testimony - Report to the Congress: Medicare Payment Policy, March 15, 2011
Sponsoring organization: Medicare Payment Advisory Commission
Presents the annual review with recommendations for Medicare fee-for-service (FFS) payment systems and the Medicare Advantage (MA) program.
Date: 03 / 2011
National Health Expenditure Projections: 2010-2020
Sponsoring organization: Centers for Medicare and Medicaid Services
Presents an analysis of projected national health care expenditures (NHE) through 2020. Updated annually.
Date: 01 / 2011
New Project Targets CAH Quality Measures and Reporting
Author(s): Candi Helseth
Sponsoring organization: Rural Assistance Center
Discusses MBQIP, the Flex Medicare Beneficiary Quality Improvement Project, which is helping Critical Access Hospitals improve patient care quality and operations, and more accurately report rural health care quality.
Journal citation: Rural Monitor
Date: 11 / 2011
Patient Protection and Affordable Care Act
Sponsoring organization: U.S. Government Printing Office
Includes the entire text of the 2010 health care reform law - The Patient Protection and Affordable Care Act, commonly referred to as the Affordable Care Act (ACA).
Date: 01 / 2010
Patient Protection and Affordable Care Act - Positive Steps for Rural
Sponsoring organization: National Rural Health Association
Examines the provisions in the Patient Protection and Affordable Care Act, and the subsequent Reconciliation Package that contains building blocks to improve the access to health care crisis faced by rural patients. Improvements include provisions to help resolve the workforce shortage crisis in rural areas and to eliminate long-standing payment inequities for rural providers.
Date: 04 / 2010
Physician's Guide to Medicare's Home Health Certification, Including the Face-to-Face Encounter
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides education on the contents of the home health certification, including homebound criteria and requirements for the face-to-face encounter and documentation needed. Includes guidance that physicians, non-physician practitioners, physician support personnel, and home health agencies can use to ensure that all certification requirements are understood and met.
Date: 05 / 2012
Rural Health Clinic: Rural Health Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Presents facts about the Rural Health Clinics program that includes the requirements for a facility to become an RHC, Medicare payments for RHC services, and a list of rural health websites.
Date: 10 / 2011
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide
Sponsoring organization: Centers for Medicare and Medicaid Services
Describes the information FQHCs are required to submit for a Prospective Payment System (PPS), and it explains how RHCs should bill for certain preventive services under the Affordable Care Act.
Date: 2009
Rural Issues Related to Bundled Payments for Acute Care Episodes (Policy Brief)
Author(s): Robert Town, Walter Gregg, Ira Moscovice, Shailendra Prasad, Jill Klingner, Christopher Dickerson
Sponsoring organization: Upper Midwest Rural Health Research Center
Describes challenges to implementing bundled payments in rural settings and discusses potential contracting and reimbursement strategies to address these challenges.
Date: 06 / 2009
Rural Medicare Advantage 2011: Enrollment Trends and Plan Characteristics
Author(s): Leah Kemper, Lisa Pollack, Abigail Barker, Timothy D. McBride, Keith J. Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Addresses the current and future plan, characteristics, and enrollment trends of the Medicare Advantage program specific to rural America.
Date: 10 / 2011
Rural Referral Center: Rural Health Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information on the Rural Referral Center (RCC) program, which supports high-volume rural hospitals that treat a large number of complicated cases. Includes list of CMS Regional Office Rural Health Coordinators.
Date: 01 / 2011
Rural Relevance Under Healthcare Reform: A Performance-Based Assessment of Rural Health Care in America
Highlights the rural healthcare delivery systems using the latest Medicare shared Savings data files, the first nationwide hospital rating system to evaluate rural hospitals, and the industry’s largest proprietary rural Emergency Department database.
Date: 04 / 2012
Sole Community Hospital: Rural Health Fact Sheet Series
Sponsoring organization: Centers for Medicare and Medicaid Services
Presents information on Sole Community Hospitals including classification payments and criteria, resources, and a list of regional office rural health coordinators.
Date: 11 / 2011
Timeline for Health Care Reform Implementation: Health Insurance Provisions
Sponsoring organization: Commonwealth Fund
Presents a timeline, which outlines when the various health insurance provisions will go into effect, from 2010 - 2018.
Date: 04 / 2010
Uninsured: A Primer - Key Facts About Americans Without Health Insurance
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
Reviews the basic profile of the uninsured population, how they receive care, the latest trends in health insurance coverage, and what the options are for increasing coverage. Includes Supplemental Data Tables.
Date: 10 / 2011
Journals
Medicare & Medicaid Research Review (MMRR)
Peer-reviewed, online journal reporting data and research that informs current and future directions of the Medicare, Medicaid, and Children's Health Insurance programs. The journal seeks to examine and evaluate health care coverage, quality and access to care for beneficiaries, and payment for health services.
Medicare Quarterly Provider Compliance Newsletter
A quarterly newsletter to help health care providers avoid common Medicare billing errors and comply appropriately with payment audits.
MLN Matters
Presents articles for Medicare health care providers to help them understand new or changed Medicare policy.
Organizations
Center for Medicare Advocacy (CMA)
National organization
Consists of a national non-profit, non-partisan education and advocacy organization that identifies and promotes policy and advocacy solutions to ensure that elders and people with disabilities have access to Medicare and quality health care. Focuses on people with chronic conditions and those in need of long term care.
Centers for Medicare and Medicaid Services (CMS)
Federal government
Operates the Medicare and Medicaid programs - two national health care programs that benefit millions of Americans. Part of the U.S. Department of Health and Human Services. Website includes access to research, statistics, and data related to their programs.
Medicare Payment Advisory Commission (MedPAC)
Federal government
Consists of an independent federal body that advises the U.S. Congress on issues affecting the Medicare program. Analyzes access to care, quality of care, and other issues affecting Medicare.
Technical Assistance and Services Center (TASC)
National organization
Assists states with all aspects of the Medicare Rural Hospital Flexibility Program (Flex Program), including Critical Access Hospitals (CAH) conversion, networking, EMS and performance improvement. TASC is the technical assistance center for the Flex Program, and a program of the National Rural Health Resource Center.
Terms & Acronyms
Accountable Care Organization (ACO) Team of doctors, hospitals, and other health care providers working together to coordinate and optimize care for enrolled Medicare recipients.
Approved Amount The fee Medicare sets as reasonable for a covered medical service. It may be less than the actual amount charged. Approved amount is sometimes called "approved charge."
CMS (Centers for Medicare and Medicaid Services) Federal agency responsible for the Medicare and Medicaid programs. Part of the U.S. Department of Health & Human Services.
Critical Access Hospital (CAH) Rural hospitals with fewer than 25 acute care beds located at least 35 miles, or 15 by mountainous terrain or secondary roads, from the nearest hospital unless designated as a “Necessary Provider” by a state plan.
Dual Eligibles Individuals who are entitled to Medicare and eligible for some level of assistance from their state Medicaid program. They are among the sickest and poorest individuals covered by Medicare or Medicaid and are very low-income individuals.
Durable Medical Equipment (DME) As defined by Medicare, is equipment which can 1) withstand repeated use, 2) is primarily and customarily used to serve a medical purpose, 3) generally not useful to a person in the absence of an illness or injury, and 4) is appropriate for use in the home (e.g. wheelchairs, hospital beds, walkers).
Federally Qualified Health Center (FQHC) FQHCs include all organizations receiving grants under section 330 of the Public Health Service Act, certain tribal organizations, and FQHC Look-Alikes. FQHCs benefit from enhanced reimbursement from Medicare and Medicaid under the prospective payment system.
ICD-10 (International Statistical Classification of Diseases and Related Health Problems) The 10th version of the International Statistical Classification of Diseases and Related Health Problems. Medical classification list for the coding of diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the World Health Organization. Comprised of over 14,000 codes and permits the tracking of many new diagnoses.
Interim Payment Rate Medicare all-inclusive rate calculated by dividing the Medicare allowable costs by number of Medicare allowable encounters. Each RHC receives this amount for each Medicare covered RHC visit throughout the clinic's fiscal year. At the end of the fiscal year, payments for the year are reconciled based on a cost report. The interim payment rate is recalculated annually.
Meaningful Use Refers to the meaningful use of certified electronic health record technology to achieve certain healthcare quality, safety, and efficiency goals. Eligible professionals, hospitals, and critical access hospitals must attest that they've met their respective meaningful use criteria and are eligible to receive Medicare incentive payments for the installation and use of electronic health record systems under the American Recovery and Reinvestment Act of 2009.
Medicaid Federal assistance program that helps pay for medically necessary services for needy and low income individuals. The program uses state and federal funds to compensate medical providers serving these populations.
Medicare Federal health care insurance program for most adults age 65 and older and certain disabled individuals. It pays for long term care under limited circumstances and for limited periods of time.
Medicare Administrative Contractor (MAC) Will replace the current Medicare fiscal intermediaries and carriers and handle administration of both the Medicare Part A and Part B programs in specified geographic regions.
Medicare Advantage Prescription Drug Plan (MAPD) Plans that cover both drugs and other Medicare benefits, such as HMO's.
Medicare Conditions of Participation (CoP) CMS conditions that health care organizations must meet to participate in the Medicare and Medicaid programs. Used to improve quality and protect the health and safety of beneficiaries.
Medicare Economic Index (MEI) Medical inflation rate. Used to adjust reimbursement caps on annual basis.
Medicare Health Plan A plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan.
Medicare Part A (Hospital Insurance Program) Hospital insurance that helps pay for inpatient hospital care, limited skilled nursing care, hospice care, and some home health care. Most people get Medicare Part A automatically when they turn 65.
Medicare Part B (Supplementary Medical Insurance Program) Medical insurance that helps pay for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover (like some home health care). Part B helps pay for these covered services and supplies when they are medically necessary. A monthly premium must be paid to receive Part B.
Medicare Part C (Medicare Advantage) (MA) Covers Part A and B services and most prescription drugs for beneficiaries who enroll in private health insurance plans such as health maintenance organization (HMO), preferred provider organization (PPO), or private fee-for-service (PFFS) plan. These plans receive payments from Medicare to provide Medicare-covered benefits, including hospital and physician services, and in some cases, prescription drug benefits. These plans offer combined coverage of Part A, Part B, and in some cases, Part D (prescription drug) benefits.
Medicare Part D (Prescription Drug Plans) (PDPs) Provides outpatient prescription drug coverage that is delivered through private plans that contract with Medicare. The benefit includes additional assistance with plan premiums and cost-sharing amounts for low-income beneficiaries. People enrolled in Medicare drug plans pay a monthly premium. Prescription drug benefit added to Medicare in 2006. Created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).
Medicare Payment Advisory Commission (MedPAC) An independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) Legislation passed in 2003 that included significant Medicare reforms including a prescription drug benefit for Medicare beneficiaries and reimbursement improvements for rural healthcare facilities.
Medicare Prospective Payment System (PPS) Medicare reimbursement method in which rates for services are established in advance, based on the patient's diagnosis.
Medicare Rural Hospital Flexibility Program (Flex Program) Federal initiative created by the Balanced Budget Act of 1997 that provides funding to State Governments to strengthen rural health. Requires the development of state rural health plan. Provides funding to States network development, quality improvement, designation of Critical Access Hospitals (CAHs), and improvement of rural EMS.
Medigap A Medicare supplement insurance policy sold by private insurance companies to fill gaps in Original Medicare Plan coverage.
MedPAC Stands for Medicare Payment Advisory Commission
Out-of-Pocket Costs Health care costs that you must pay on your own because they are not covered by Medicare.
Patient Protection and Affordable Care Act (PPACA) Is a Federal statute, signed into law on March 23, 2010. This Act, along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010) make up the health care reform of 2010. The laws focus on reform of the private health insurance market, provide better coverage for those with pre-existing conditions, improve prescription drug coverage in Medicare, and extend the life of the Medicare Trust fund by at least 12 years.
Private Pay Patients Patients who pay for their own care or whose care is paid for by their family or another private third party, such as an insurance company. The term is used to distinguish patients from those whose care is paid for by governmental programs (Medicaid, Medicare, and Veterans Administration).
Provider Identification Number (PIN) Unique number issued by payers to each provider to identify that provider as a credentialed and approved provider. Also known as a Medicare billing number.
Quality Improvement Organization (QIO) QIOs review Medicare services. They work with consumers, physicians, hospitals, and other caregivers to make sure patients get the right care at the right time, particularly among underserved populations.
Regional Home Health Intermediaries A private company that contracts with Medicare to process claims and make checks of home health care.
Rural Health Clinic (RHC) Clinic certified to receive special Medicare and Medicaid reimbursement. RHCs must be located in underserved rural areas and provide primary care services. RHCs use a team approach of physicians, nurse practitioners, physician assistants, and certified nurse midwives to provide services. Payment is based on a cost-related basis for outpatient physician and certain nonphysician services.
Swing beds Licensed acute-care beds designated by a hospital to provide either acute or long-term care services. A swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare that has CMS approval to provide post-hospital skilled nursing facility care and meets certain requirements.
TASC (Technical Assistance and Services Center) The technical assistance center for the Medicare Rural Hospital Flexibility Program (Flex Program). Provides information, tools and resources on all aspects of the Flex Program, including CAH, networking, EMS, and quality improvement. TASC is run by the Rural Health Resource Center in Duluth, MN.
True Out-of-Pocket Costs (TrOOP) Drug costs paid by a Medicare enrollee, or on behalf of an enrollee by a family member, charitable organization, or State Pharmacy Assistance Program.
UPIN (Unique Provider Identification Number) Six-character alphanumeric identifier assigned to all Medicare physicians, medical groups and non-physician practitioners.
Version 5010 Also referred to as HIPAA X12 Version 5010. This is a new set of standards that regulates the electronic transmission of specific healthcare transactions. Covered entities, such as health plans, health care clearinghouses, and health care providers, are required to conform to these standards. The deadline date for this change has been changed several times. Currently, the deadline is after June 20, 2012.
Version D.O This is the new version of the National Council for Prescription Drug Programs (NCPDP) standards for pharmacy transactions that replaces version 5.1. Mandatory compliance date is January 1, 2012.
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