	Introduction

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 B, the Supplementary Medical Insurance program, covers a broad range of medical services including physician services, laboratory services, durable medical equipment, and outpatient hospital services. Part C (also known as Medicare Advantage, or MA) provides private plan options, such as managed care, for beneficiaries who are enrolled in both Parts A and B. Part D provides optional outpatient prescription drug coverage. Medicare Payment Rules

Medicare has established specific rules governing payment for covered services. Payments for physician services, clinical laboratory services, and certain durable medical equipment covered under Part B are made on the basis of fee schedules. In general, the program provides for annual updates of the program payments to reflect inflation and other factors. However, updates to the physician fee schedule are determined by a statutory formula, known as the sustainable growth rate (SGR) system, which links annual updates to how cumulative actual expenditures compare with a cumulative expenditures target. Beneficiary Out-of-Pocket Payments

In addition to premiums, there are two aspects of beneficiary payments to providers: required cost-sharing amounts (coinsurance, copayments, or deductibles) and the amounts that beneficiaries may be billed over and above Medicare's recognized payment amounts for certain services. For Part C, cost sharing is determined by the private plans. The bidding mechanism established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) allows plans to charge a premium to cover basic Medicare benefits if the costs to the plan exceed the maximum amount the Centers for Medicare & Medicaid Services (CMS) will pay for Medicare-covered benefits. Under Part A, providers agree to accept Medicare's payment as payment in full and cannot bill a beneficiary amounts in excess of the coinsurance and deductibles. Recent Congressional Actions with Respect to Payments

Because of its rapid growth, both in terms of aggregate dollars and as a share of the federal budget, the Medicare program has been a major focus of legislative attention, as outlined below. With a few exceptions, savings in program spending have been achieved largely through reductions in the updates to provider payments, primarily hospitals, physicians, and MA plans. Though the ACA payment changes to Medicare providers and plans is expected to slow the growth in Medicare spending and extend the solvency of the Hospital Insurance (Part A) Trust Fund, some have suggested that such a policy may not be sustainable in the long run, "without unprecedented improvements in health care provider productivity." Unlike other agencies that advise Congress, IPAB's recommendations are to be automatically implemented unless Congress acts. Payments for most Medicare benefits will be subject to a maximum 2% reduction each year from March 2013 through 2021. In the case of Medicare Parts C and D, reductions are made to the monthly payments made to the private plans that administer these parts of the program. This report provides a guide to Medicare payment rules by type of benefit. The first column in each table lists the type of payments that may be received by the provider (e.g., the separate operating and capital payments paid to short-term general hospitals under the prospective payment system as described in Medicare Payment Policies ( Table 1 ), or lists subcategories of providers under the general provider category (such as the different types of non-physician providers that are all listed in Table 7 ). A complete list of acronyms used in this report is included the Appendix . This report is updated to reflect the most recent legislative changes to the program and payment updates available through January 2013.
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.