Medicare Basics

General information about the Medicare program, Medicare beneficiaries, and Medicare Administrative Contractors is provided on this webpage.

What is Medicare?

The Medicare program is a federal health insurance program for people aged 65 or older, certain persons with disabilities, and persons of any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) or Lou Gehrig's disease. It is governed by the Centers for Medicare & Medicaid Services (CMS), which is a division of the U.S. Department of Health and Human Services. Social Security Administration (SSA) offices across the country take applications for Medicare and provide general information about the program. The SSA is also responsible for any changes or termination of a patient's Medicare enrollment.

There are four parts to the Medicare Program. Hospital Insurance (Part A) helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, home health care, and hospice care. Medical Insurance (Part B) helps pay for medically necessary services by a physician, outpatient hospital services, home health care, and a number of other medical services and supplies that are not covered by Part A, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). All topics covered in this manual refer to Medicare Part B DMEPOS. Enrollment in Part B is optional. Part A and Part B are often referred to as Original Medicare.

An alternative to the original Part A and Part B Medicare are the Medicare Health Plans, Medicare Advantage Plans and Medical Savings Accounts, referred to as Medicare Part C. These are health plan options that are approved by Medicare and administered by private insurance companies. Claims for patients with Medicare Part C must be filed with the contractor of that particular plan and not to a Part A intermediary, Part B carrier, A/B MAC or DME MAC. Do not file claims for Part C to our office. Enrollment in Part C is optional.

These Medicare Advantage Plans can be classified as risk or cost. If a beneficiary has a cost Medicare Advantage Plan, they can choose who they want to be billed: original Medicare or the Medicare Advantage Plan, but not both. Risk Health Maintenance Organizations (HMOs) replace Medicare coverage; Medicare is not secondary.

Medicare also offers prescription drug coverage (Part D) to everyone with Medicare. This coverage may help lower prescription drug costs and help protect against higher costs in the future. Private companies provide this coverage. Beneficiaries choose the drug plan and pay a monthly premium. Enrollment in Part D is optional.

The beneficiary must meet a deductible* each calendar year before payment can be made by Medicare Part B. The beneficiary may be billed for any amount applied to the deductible. It is a business practice decision for the supplier to collect the deductible from the beneficiary at the time of service or after the claim has been processed.

*Note: The Medicare Part B deductible for 2018 is $183.00. The deductible is subject to change every year.

Noridian's Role as a DME MAC

CMS selected two insurance companies to process DMEPOS claims for the Medicare Fee-for-Service program. These companies function as Durable Medical Equipment Medicare Administrative Contractors (DME MACs). The DME MACs are divided into four geographical jurisdictions (A-D).

Each jurisdictional contractor is responsible for handling DMEPOS claims for beneficiaries residing in their jurisdiction.

Noridian is the DME MAC for Jurisdiction A and D. Jurisdiction A includes Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont, and the District of Columbia. Jurisdiction D includes Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, N. Mariana Islands, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming. Noridian's role is to process and pay Medicare claims according to Title XVIII of the Social Security Act, Health Insurance regulations, and CMS rulings. Please refer to the citations provided throughout this manual. Citations are included for CMS manuals This link will take you to an external website. that contain Medicare regulations.

Note: While attempts have been made to include all relevant citations to the appropriate legal authority, i.e., statutory, regulatory, and agency, there may be inadvertent omissions. Noridian encourages users to carefully research all citations for appropriateness and applicability. The referenced citations should not be considered the only sources of regulatory authority.

Noridian began operating in 1966 as a division of Noridian Mutual Insurance Company. At that time, its business operations consisted solely of administering the federal Medicare program in one state. Noridian now administers the Medicare program as a Medicare Administrative Contractor (MAC) for Jurisdictions E and F. Jurisdiction E serves Part A and Part B providers in the states of California, Hawaii and Nevada as well as Guam, American Samoa and the Northern Mariana Islands. Jurisdiction F serves Part A and Part B providers in the states of Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming. Noridian is also the contractor for the Pricing, Data, Analysis and Coding (PDAC).

Medicare Card

Sample Medicare Card

For convenience and reference, it is recommended that suppliers keep a copy of each beneficiary's Medicare card in their files. The card shows important information including: the beneficiary's name, Medicare ID, and effective dates of enrollment to the hospital and/or medical plans of Medicare. Please note the beneficiary may not have both Medicare Part A and B, as Part B is elective. Pay close attention to the lower part of the beneficiary's Medicare card which shows the enrollment plan(s) and effective date. The beneficiary must have Medical Insurance (Part B) displayed on his/her card in order for DMEPOS services to be eligible for coverage.

In order for Medicare claims to process correctly, the beneficiary's complete name, as it appears on the card, and the Medicare ID should be correctly entered on all Medicare claims. Information that does not match eligibility records will cause suspension or denial of claims.

Note: The Medicare ID is made up only of numbers and uppercase letters. The numbers and letters have no special meaning. The Medicare ID will be 11-characters in length.

Note: If the beneficiary you are servicing displays that he/she has "hospital insurance benefits only", supplier services CANNOT be paid for by Medicare, so please check eligibility before providing services.

Resource: CMS Internet Only Manual Publication 100-01, Medicare General Information, Eligibility, and Entitlement, Chapter 2, Section 50 This link will take you to an external website.

Termination of Enrollment

There are times when a beneficiary's enrollment in Medicare may terminate for various reasons. This may not be reflected on the Medicare card. If a denial from Medicare is received indicating no entitlement for the dates of service on the claim, there are several items that can be checked:

  1. Was the correct Medicare ID copied from the Medicare card?
  2. All letters and numbers are important.
  3. Is this the correct date of service? Be sure to check the year.

Has the beneficiary's enrollment been terminated? Check with the beneficiary to verify this fact. The contractor generally does not have any details regarding termination of a beneficiary's enrollment.

Resource: CMS Internet Only Manual Publication 100-01, Medicare General Information, Eligibility, and Entitlement, Chapter 2 This link will take you to an external website.

Other Government Insurance Plans

Railroad Retirement Board

Claims for DMEPOS items for beneficiaries eligible for Railroad Retirement Board (RRB) benefits are also handled by Noridian for beneficiaries in Jurisdiction A. You will no longer be able to distinguish RRB patients by the number on the new Medicare card. You'll be able to identify a beneficiary covered by RRB by looking at the RRB logo on their card. If suppliers have any questions regarding RRB, the beneficiary should have a Medicare Handbook for RRB that will provide answers.

United Mine Workers Association

There is no easily recognizable number for beneficiaries with coverage by the United Mine Workers Association (UMWA). The beneficiary should be able to advise if his/her coverage is through UMWA. In the event a claim is filed to our office for UMWA, the claim will be forwarded to the appropriate office. A statement to that effect will be printed on the Medicare Remittance Notice (MRN) if the claim is assigned and will also be printed on the beneficiary's Medicare Summary Notice (MSN). These notices will let the supplier and the beneficiary know that future claims should be filed with the appropriate office.

Resources