Medicare Program Overview

From the Centers for Medicare and Medicaid

Medicare is a health insurance program for:

  • people age 65 or older,
  • people under age 65 with certain disabilities, and
  • people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has:

Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services.

Medicare deductible and premium rates may change every year in January.

Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

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Oregon's Medicare Part B Carrier

Noridian Healthcare Solutions is the Medicare Part B carrier for Oregon. Their website, is very useful for obtaining the latest news regarding Medicare Part B as well as obtaining any necessary Medicare forms for your practice.

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Noridian Healthcare Solutions has a comprehensive website on Medicare Part B Enrollment information, which includes necessary forms and educational resources:

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Medicare Reimbursement Resources and the SGR

The Sustainable Growth Rate (SGR) is a component of the CMS formula used  to calculate physician payments for providing services to Medicare patients. It is based on the GDP and not on actual health care practice costs.

  • The SGR will lead to steep cuts in physician compensation for services to Medicare patients. The SGR is a target expenditure growth number. If actual expenditures exceed the SGR, physicians’ payments are cuts.

The SGR is based on the following factors:

  • Estimated change in fees for physician's services.
  • Estimated change in beneficiaries enrolled in Medicare's fee-for-service program.
  • Estimated growth in real gross domestic product (GDP) per capita.
  • Estimated change in expenditures due to law and regulation.

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v2 2016