MLN Matters Number: MM6690
Related Change Request (CR) #: 6690
Related CR Release Date: November 13, 2009
Effective Date: January 1, 2010
Related CR Transmittal #: R61GI
Implementation Date: January 4, 2010
Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (fiscal intermediaries (FI), regional home health intermediaries (RHHI), Medicare Administrative Contractors (A/B MAC), Durable Medical Equipment Medicare Administrative Contractors (DME MAC) and carriers) for services provided to Medicare beneficiaries.
Impact on Providers
This article is based on Change Request (CR) 6690, which provides the Medicare rates for deductible, coinsurance, and premium payment amounts for calendar year (CY) 2010.
2010 Part A - Hospital Insurance (HI)
A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount that the Medicare program pays the hospital for inpatient hospital services it furnishes in an illness episode. When a beneficiary receives such services for more than 60 days during an illness encounter, he or she is responsible for a coinsurance amount that is equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital.
Please note that an individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible.
In addition, a beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during an illness episode. The 2010 deductible and coinsurance amounts are in the following table.
Table 1
2010 Part A – Hospital Insurance (HI)
Deductible: $1,100.00
|
Hospital Coinsurance
|
Hospital Coinsurance
|
Skilled Nursing
Facility Coinsurance
|
|
Days 61-90
|
Days 91-150
(Lifetime Reserve
Days)
|
Days 21-100
|
|
$275.00
|
$550.00
|
$137.50
|
Most individuals age 65 and older (and many disabled individuals under age 65) are insured for Health Insurance (HI) benefits without a premium payment. In addition, the Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly Part A premium.
Since 1994, voluntary enrollees may qualify for a reduced Part A premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person’s initial enrollment period, a 2-year 10% penalty is assessed for every year they had the opportunity to (but failed to) enroll in Part A. The 2010 Part A premiums are listed in table 2, below.
Table 2
Voluntary Enrollees Part A Premium Schedule for 2010
|
Base Premium (BP)
|
Base Premium with 10% Surcharge
|
|
$461.00 per month
|
$507.10 per month
|
2010 Part B - Supplementary Medical Insurance (SMI)
Under Part B, the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. In addition, most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. Further, when Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10% increase in the premium for each year the beneficiary had the opportunity to (but failed to) enroll.
For 2010, the standard premium for SMI services is $110.50 a month; the deductible is $155.00 a year; and the coinsurance is 20%. The Part B premium is influenced by the beneficiary’s income and can be substantially higher based on income. The higher premium amounts and relative income levels for those amounts are contained in CR 6690, which is available at www.cms.hhs.gov/Transmittals/downloads/R61GI.pdf on the CMS website.
|
Base premium with 45% Reduction
|
Base premium with 45% Reduction
and 10% surcharge
|
|
$254.00 per month (for those who
have 30-39 quarters of coverage)
|
$279.40 per month
|
Additional Information
If you have questions, please contact the Palmetto GBA Provider Contact Center at their toll-free number, (866) 801-5301.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.