Medicare Eligibility And Benefits Verification

S To Verify Eligibility

• Providers are asked to verify member eligibility by using the Sunshine Health secure provider portal. Using the portal, any registered provider is able to quickly check member eligibility by indicating the date of service, member name, and date of birth or the Medicaid ID number and date of birth.
• Providers may call Provider Services at 1-844-477-8313. Providers are asked to supply the members name and date of birth or the members Medicaid identification number and date of birth.

Medicare Has Four Parts

Medicare is split into parts, each identified by a letter: A, B, C, and D.

When a person has both Parts A and B, this is called having Original Medicare.Part D covers prescription drugs only.

Part C is slightly different it combines the coverage of Parts A, B, and D under a type of plan called Medicare Advantage.

We explore all of these parts of Medicare below.

Medicare Part A: Hospital Insurance covers for inpatient services when admitted to the hospital, as well as home health care, skilled nursing care and Hospice. Part A may require a premium depending on work history while paying taxes, but typically beneficiaries are entitled to it at no cost. Individuals receiving at least four months of Railroad Retirement Board Benefits or Social Security benefits before they turned 65 will be automatically enrolled. Others must contact Social Security to enroll in Part A of Medicare.

Medicare Part B: Medical Insurance is outpatient physician care that includes doctors visits and other medical services as well as durable medical equipment for home use. Part B requires a premium in most cases. In 2021, this monthly premium is $148.50.

You can start here and now Medicare costs and insurance options at no cost!

Medicaid And Child Welfare Specialty Plan

Until the actual date of enrollment with Sunshine Health, Sunshine Health is not financially responsible for services the prospective member receives. In addition, Sunshine Health is not financially responsible for services members receive after coverage is terminated. However, Sunshine Health is responsible for anyone who is a Sunshine Health member at the time of a hospital inpatient admission and changes health plans during that confinement.

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Point And Click License For Use Of Current Dental Terminology

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition , copyright © 2002, 2004 American Dental Association . All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED “I ACCEPT”, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED “I DO NOT ACCEPT” AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, “YOU” AND “YOUR” REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Ihcp Provider Healthcare Portal

The IHCP Provider Healthcare Portal is a secure website that allows providers to perform multiple functions including obtaining eligibility information and filing FFS claims. The Portal is fast and easy to use, and online help is available through the eligibility verification process. For more information, see the provider reference module.

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Already Enrolled In Medicare

If you have Medicare, you can get information and services online. Find out how to .

If you are enrolled in Medicare Part A and you want to sign up for Part B, please complete form CMS-40B, Application for Enrollment in Medicare Part B . If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information.

You can use one of the following options to submit your enrollment request under the Special Enrollment Period:

Note: When completing the forms CMS-40B and CMS-L564:

• State I want Part B coverage to begin in the remarks section of the CMS-40B form or online application.
• If possible, your employer should complete Section B.
• If your employer is unable to complete Section B, please complete that portion as best as you can on their behalf and submit one of the following forms of secondary evidence:
• Income tax form that shows health insurance premiums paid.
• W-2s reflecting pre-tax medical contributions.
• Pay stubs that reflect health insurance premium deductions.
• Health insurance cards with a policy effective date.
• Explanations of benefits paid by the GHP or LGHP.
• Statements or receipts that reflect payment of health insurance premiums.

Some people with limited resources and income may also be able to get .

North Carolina Medicaid Eligibility

Beyond the standard financial requirement, North Carolina looks at several factors in determining whether your application for benefits will be accepted. These include family size, need for long-term care, ability level, and if you receive Medicare.

Which Medicaid plan is best in North Carolina?

North Carolina provides different levels of coverage based on the above-mentioned factors, as well as other benefits for children and pregnant women. What coverage you qualify for depends on your level of medical and financial need.

Youll need to submit an online application to the Department of Health and Human Services.

North Carolina Medicaid Application:

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Individual Is Dual Eligible

Revision 22-1 Effective Nov. 28, 2022

Many people who live in NFs are eligible for both Medicaid and Medicare. A NF stay for a person admitting from an acute care hospital may initially be funded by Medicare. However, the persons Medicaid eligibility, and therefore their eligibility for PASRR, does not change. If the person is Medicaid-eligible and meets the other criteria for habilitation coordination, he or she must not be refused access to those services whether or not the current stay is paid for by Medicare or Medicaid.

Responsibility To Reestablish Medicaid Eligibility

Revision 22-1 Effective Nov. 28, 2022

If a person loses Medicaid eligibility or is delayed in having Medicaid eligibility determined or re-determined, a NF and LIDDA may be unable to receive authorizations or bill for PASRR specialized services, including habilitation coordination. It is the responsibility of the representative payee to contact the appropriate entity to determine the necessary action to reinstate benefits.

If the individual or family is the representative payee, the habilitation coordinator must assist, if requested.

If the NF is the representative payee, the NF is responsible for ensuring action is taken to reestablish Medicaid eligibility. In most circumstances, assisting people with Medicaid eligibility determinations, re-determinations, and MCO selection is allowable as a medically related social service, which is a service provided by the NF that help the individual in attaining the highest practicable physical, mental, or psychosocial well-being.

If needed, the LIDDA is expected to work with the NF to help a person reestablish Medicaid eligibility. Failure of a representative payee to help reestablish Medicaid eligibility may be reported to HHSC Complaint and Incident Intake.

To minimize billing issues about habilitation coordination, LIDDAs should review the service authorization in Medicaid Eligibility Service Authorization Verification to verify that the person is admitted into the correct Medicaid program.

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Strengthen Your Rcm With A Trusted Billing Partner

Managing eligibility and benefits verification can feel daunting, especially in addition to all the other critical RCM steps. But you dont have to do it all yourself! When you partner with Greenway Revenue Services, you can benefit from specialty-specific billing expertise and a team dedicated to helping you achieve your revenue goals.

Pverifys Medicare Patient Eligibility Verification Solutions Features:

pVerify provides verified Medicare Eligibility Checks benefits at a deeper level with information separated and highlighted for easier review and understanding

• Confirm Active or Inactive Status, with Medicare A, B, & D details.
• Find out the primary insurance information if Medicare is the secondary payer.

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Unitedhealthcare Connected General Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services, 8 a.m. 8 p.m., local time, Monday Friday . The call is free.

You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future.

Language Line is available for all in-network providers.

Puede obtener este documento de forma gratuita en otros formatos, como letra de imprenta grande, braille o audio. Llame al Servicios para los miembros, de 08:00 a. m. a 08:00 p. m., hora local, de lunes a viernes correo de voz disponible las 24 horas del día,/los 7 días de la semana). La llamada es gratuita.

Puede llamar a Servicios para Miembros y pedirnos que registremos en nuestro sistema que le gustaría recibir documentos en español, en letra de imprenta grande, braille o audio, ahora y en el futuro.

The Parts Of Medicare

Social Security enrolls you in Original Medicare .

• Medicare Part A helps pay for inpatient care in a hospital or limited time at a skilled nursing facility . Part A also pays for some home health care and hospice care.
• Medicare Part B helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.

Other parts of Medicare are run by private insurance companies that follow rules set by Medicare.

• Supplemental policies help pay Medicare out-of-pocket copayments, coinsurance, and deductible expenses.
• Medicare Advantage Plan includes all benefits and services covered under Part A and Part B prescription drugs and additional benefits such as vision, hearing, and dental bundled together in one plan.
• Medicare Part D helps cover the cost of prescription drugs.

Most people age 65 or older are eligible for free Medicare hospital insurance if they have worked and paid Medicare taxes long enough. You can sign up for Medicare medical insurance by paying a monthly premium. Some beneficiaries with higher incomes will pay a higher monthly Part B premium. To learn more, read .

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What About Medigap Plans

Original Medicare covers a good portion of your care, but its not exhaustive. Theres a wide range of services that Parts A and B dont cover, including dental and vision care. About a third of Medicare enrollees choose the private version of the program Medicare Advantage because it tends to cover more than its original counterpart. But if you like the flexibility of original Medicare and dont need the benefits that Advantage affords, but you still want additional coverage to offset your out-of-pocket costs, then consider adding a Medigap supplemental policy to your plan.

Medigap insurance, as its name suggests, covers some gaps left by original Medicare. Parts A and B require copays, coinsurance and deductibles, which can add up over time. And since Medicare requires Part B enrollees to cover 20 percent of their costs without any caps in place, you may face higher bills without some protection in place. Medigap offers that protection. With a supplemental plan in place, you may have coverage for:

• Copays and Coinsurance
• Deductibles for Part A, B or both
• Medical services while traveling
• Additional time in the hospital

This is just a sampling of the benefits that Medigap offers. There are 10 plan types, labeled A through N, and each plan type is standardized in all but three states . You can read more about Medigap here or Medicare.gov, but were mentioning it in this article because theres a relatively brief window of time to enroll in Medigap with open eligibility.

How To Use An Insurance Verification Training Manual To Support Insurance Eligibility

Because the insurance eligibility verification process can be complicated, long term care facilities should have an insurance verification training manual to help staff learn the insurance eligibility verification process. This helps nursing home staff better understand the health insurance process and how it impacts patient care and the payment process.

Long term care facilities must offer sufficient training in the insurance eligibility verification process because patients may not fully understand their insurance policies. In such cases, the facilitys staff will need to explain the procedures when they are asked insurance-related questions. Therefore, if a facility creates a good payment culture, there will be fewer payment issues and conflicts. These processes can be facilitated by using a long term care software system that includes online training programs.

A typical insurance verification training manual will include information on verification training, eligibility in the revenue cycle, information on members cards, and the facilitys medical billing process. Some state manuals may also include templates and examples on verifying eligibility and co-payment so staff can complete the insurance eligibility verification process accurately.

Contact us here if you would like to test drive our user-friendly long term care software.

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Should I Sign Up For Medical Insurance

With our online application, you can sign up for Medicare Part A and Part B. Because you must pay a premium for Part B coverage, you can turn it down.

If youre eligible at age 65, your Initial Enrollment Period begins three months before your 65th birthday, includes the month you turn age 65, and ends three months after that birthday.

Note: Important Upcoming Change Rules for 2023 and later: If you accept the automatic enrollment in Medicare Part B or if you sign up during the first three months of your IEP, your coverage will start the month youre first eligible. Beginning January 1, 2023, if you sign up during the month you turn 65 or during the last three months of your IEP, your coverage starts the first day of the month after you sign up.

The following chart shows when your Medicare Part B becomes effective in 2022:

The following chart shows when your Medicare Part B becomes effective in 2023:

I’m On Disability When Will I Be Eligible For Medicare

You may be eligible for Medicare before age 65 if you have a qualifying disability. Eligibility usually starts after you’ve received disability benefits for 24 months. You will be automatically enrolled in Medicare Parts A and B. You may make other coverage choices during your IEP. Your 7-month IEP includes the month you receive your 25th disability check plus the 3 months before and the 3 months after.

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Individual Does Not Have An Mco

Revision 22-1 Effective Nov. 28, 2022

If a LIDDA becomes aware that a person is not assigned an MCO, the LIDDA must contact the NF and request the NF give information and guidance to the person or LAR on how to select and enroll in an MCO. The LIDDA must not delay transition planning activities if the person does not have an MCO and is ready to transition to the community.

Note: As part of medically related social services, a NF may provide information to a person or the persons LAR about available MCOs and guidance on how to enroll in the preferred MCO. A NF may not choose an MCO on behalf of the individual.

What Do I Need To Do When I’m Eligible For Medicare

After you become eligible for Medicare it’s time to enroll. You will need to enroll in Medicare Part A and/or Part B first before you can enroll in any additional coverage.

Some people are automatically enrolled in Original Medicare once they’re eligible, but not everyone is.

You’ll be automatically enrolled in Original Medicare if:

• You’re receiving Social Security or Railroad Retirement Board benefits when you turn 65 or

• You’re eligible for Medicare because of a disability or medical condition.

You must enroll yourself in Original Medicare if:

• You’re not receiving Social Security benefits when you become eligible for Medicare.

There are three ways to enroll yourself in Medicare:

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Access Detailed Medicare Eligibility Information In Real

ABILITY CHOICE Medicare Eligibility gives providers 24/7 access to the Medicare benefits information they need. With multiple search criteria options, this Medicare eligibility verification software delivers instant, detailed results even if not all patient information is available for the inquiry.

The application allows staff to:

• Use enhanced filtering to customize Service Type Code selection and save preferred options to see only the benefit responses you need to see
• Track deductibles and benefits including therapy cap amounts, applied and remaining amounts, hospital and skilled nursing facility co-pay days remaining, and lifetime reserve days remaining
• See Medicare eligibility for all states and lines of business including Part A, Part B, Medicare Education Resource Center , regional home health intermediaries , and Railroad all in one place