Paulette C. Morgan, Coordinator
Specialist in Health Care Financing
Cliff Binder
Analyst in Health Care Financing
Patricia A. Davis
Specialist in Health Care Financing
Jim Hahn
Specialist in Health Care Financing
Suzanne M. Kirchhoff
Analyst in Health Care Financing
Scott R. Talaga
Analyst in Health Care Financing
Sibyl Tilson
Specialist in Health Care Financing
Medicare is a federal insurance program that pays for covered health services for most persons 65 years of age and older and for most permanently disabled individuals under the age of 65. Part A of the program, the Hospital Insurance program, covers hospital, post-hospital, and hospice services. Part B, the Supplementary Medical Insurance program, is optional and covers a broad range of complementary medical services including physician, laboratory, outpatient hospital services, and durable medical equipment. Part C provides private plan options for beneficiaries enrolled in both Parts A and B. Part D is an optional outpatient prescription drug program.
Medicare has established specific rules for payment of covered benefits. Some, such as physician services and most durable medical equipment, are based on fee schedules. A fee schedule is a list of Medicare payments for specific items and services, which are calculated according to statutorily specified formula and take into account the actual amount of care provided. Many services, including inpatient and outpatient hospital care, are paid under different prospective payment systems (PPSs). A prospective payment system is a method of paying hospitals, or other providers, amounts or rates of payment that are established in advance for a defined period and are generally based on an episode of care, regardless of the actual amount of care used. Other payments are based, in part, on a provider’s bid (an estimate of the cost of providing a service) relative to a benchmark (the maximum amount Medicare will pay). Bids and benchmarks are used to determine payments in Medicare Parts C and D. Payments for some items of durable medical equipment in specified locations are also based on the bids of competing providers.
In general, the program provides for annual updates to these payment amounts. The program also has rules regarding the amount of cost sharing, if any, that beneficiaries can be billed in excess of Medicare’s recognized payment levels. Unlike other services, Medicare’s outpatient prescription drug benefit can be obtained only through private plans. Further, while all Part D plans must meet certain minimum requirements, they differ in terms of benefit design, formulary drugs, premiums, and cost-sharing amounts.
Medicare payment policies and potential changes to these policies are of continuing interest to Congress. The Medicare program has been a major focus of deficit reduction legislation since 1980. In each Congress since the 105th Congress, laws have been passed to both increase, but more often slow, the rate of growth of payments to Medicare providers and private plans. Perhaps of particular interest in the 113rd Congress is the update to the Medicare physician fee schedule. The method for updating the physician fee schedule amount, known as the sustainable growth rate (SGR), would have resulted in negative updates for physician payments in recent years, except that Congress has stepped in to stop the updates. Physician payment rates, which would have fallen 26.5% in the absence of congressional action, are frozen through December 31, 2013. Under current law, Medicare physician fee schedule payments are to be reduced by 24.4% beginning January 2014.
This report provides an overview of Medicare payment rules by type of service, outlines current payment policies, and summarizes the basic rules for payment updates. In addition to the payment information provided in the tables of this report, Medicare is subject to a maximum 2% payment reduction due to sequestration. This report will be updated twice a year to reflect recent fiscal year and calendar year changes, and will be updated to reflect the details of how the 2% reduction in payments will be applied.
Date of Report: April 24, 2013
Number of Pages: 57
Order Number: RL30526
Price: $29.95
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