Medicare was established in 1965 by Title XVIII of the Social Security Act, and eligible individuals began enrolling in 1966. Since Medicare is the largest health insurance program in the U.S., with more than 47 million enrollees being entitled to benefits, being enrolled to see patients on and get paid by Medicare is important to any health care business owner.
The Medicare Program
The Centers for Medicare & Medicaid Services, or CMS, is the federal agency within the U.S. Department of Health and Human Services that administers and oversees the Medicare program.
Medicare consists of the following four parts:
- Part A, hospital insurance.
- Part B, medical insurance.
- Part C, Medicare Advantage (MA).
- Part D, prescription drug plan (PDP).
Part A and Part B are available to:
- Individuals who are age 65 or older.
- Individuals who are under age 65 with certain disabilities.
- Individuals with end-stage renal disease (ESRD).
When an individual becomes entitled to Medicare, CMS or the Railroad Retirement Board (RRB) will issue that individual a health insurance card.
Who Can Be a Medicare Provider?
Under Part B, the Medicare program recognizes a broad range of providers and suppliers that furnish the necessary services and supplies to meet the health care needs of beneficiaries. In addition to physicians, the program recognizes nurse midwives, clinical psychologists, optometrists, dentists and many other practitioners.
What Services Are Covered by Part B?
Some of the services that Part B, medical insurance, helps pay for include:
- Medically necessary services furnished by physicians in a variety of medical settings, including but not limited to the physician’s office, an inpatient or outpatient hospital setting, Ambulatory surgical centers or ESRD facilities.
Covered are:
- Many preventive services.
- Home health care for individuals who do not have Part A.
- Ambulance services.
- Clinical laboratory and diagnostic services.
- Surgical supplies.
- Durable medical equipment, prosthetics, orthotics and supplies.
- Hospital outpatient services.
- Services furnished by practitioners with limited licenses, such as audiologists, certified nurse midwives, clinical psychologists, physician assistants and more.
Enrolling in the Medicare Program
In order to enroll in and obtain reimbursement from Medicare, all providers and suppliers must:
- Apply for a national provider identifier (NPI).
- Enroll in the Medicare program.
In the enrollment process, CMS collects information about applicants and secures documentation to ensure that the applicant is qualified and eligible to enroll in the Medicare program. Providers and suppliers can apply for enrollment by using one of the following:
- The internet-based provider enrollment, chain and ownership system (PECOS).
- The paper enrollment process via an enrollment application (Form CMS-855).
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