Policy Medicare Policy

[Dept. Health]

Department of Health
Medicare Policy

This policy is issued under Section 5 of the Redmontian Health Service Act.
This policy establishes how Medicare operates in practice, including coverage, co-payments, billing procedures, and compliance standards.​

MEDICARE​

Medicare is the state-funded public health insurance scheme of the Commonwealth of Redmont, administered by the Department of Health under the Redmontian Health Service Act.

Medicare provides coverage only where healthcare services or treatment items are provided by Department of Health employees in the course of their official duties and in compliance with Department policy and applicable law.

MEDICARE BENEFITS SCHEDULE​

The Medicare Benefits Schedule (MBS) sets out the healthcare services and treatment items covered by Medicare, the extent of that coverage, and any applicable co-payments or conditions.

Medicare coverage for all services and treatments listed on the MBS is subject to a maximum coverage cap. Medicare shall not contribute beyond the capped amount specified in the MBS.

Medicare coverage may be provided either in-full or in-part. Where coverage is provided in-part, a co-payment is required in accordance with the Standard Co-Payment Schedule.

STANDARD CO-PAYMENT SCHEDULE
The following standard co-payments shall be set for services and treatments covered in-part.

CO-PAYMENT TIER	CO-PAYMENT AMOUNT
CP1	$15
CP2	$50
CP3	$100

HEALTH TREATMENTS
The following health treatments are covered under medicare

TREATMENT	COVERAGE TYPE	COVERAGE CAP	CO-PAYMENT TIER
Leg splint	In-Full	$100	-
Wrist splint	In-Full	$100	-
Bandage	In-Full	$150	-
Heat pack	In-Full	$150	-
Ice pack	In-Full	$150	-
Aciclovir	In-Full	$200	-
Activated charcoal	In-Full	$200	-
Antibiotics	In-Full	$200	-
Antiemetic	In-Full	$200	-
Cough syrup	In-Full	$200	-
Metrozol	In-Full	$200	-
Pain relief	In-Full	$200	-
Rehydrating solution	In-Full	$200	-
Class B Treatments	In-Part	$50	CP1

COLLECTING CO-PAYMENTS​

Where a treatment is listed on the Medicare Benefits Schedule as subject to coverage in-part, the listed co-payment MUST be collected before the treatment is administered.

The co-payment contributes towards the coverage cap and does not extend the maximum amount covered under the MBS

Co-payments MUST be made by the patient using /pay <doctor> <co-payment amount> before any treatment is provided.

MEDICARE CLAIMS​

Once a treatment or service has been lawfully administered, a doctor MUST submit a Medicare claim using the command /bulkbill <patient>.

The /bulkbill command MUST be used after each treatment in order to accurately claim the Medicare benefit specified in the MBS.

All Medicare claims submitted using /bulkbill are logged and monitored by the Department of Health. Submitting a Medicare claim constitutes an insurance claim on behalf of the Department of Health, and is subject to this policy and all applicable statute.

OUT-OF-POCKET PAYMENTS​

A patient may choose to pay for a treatment without using Medicare, or may be required to do so when their entitlement to Medicare has been revoked. In such cases, the patient MUST pay out-of-pocket using the command /pay <doctor> <amount>.

The cost of a treatment provided by the Department of Health when paid out-of-pocket is equal to the coverage cap for that treatment, as listed in the MBS.

When a patient is paying out-of-pocket, payment MUST be collected before any treatment is administered.

A patient may provide a voluntary tip in addition to any required payment, including when Medicare is used. A tip MUST NOT be used to offset or contribute toward the cost of a treatment and MUST be paid separately from any healthcare costs.

MEDICARE ABUSE POLICY​

The misuse of Medicare is strictly prohibited. When a doctor submits a Medicare claim using the /bulkbill <patient> command, they are filing an insurance claim on behalf of the Department of Health and attesting that the claim complies with the Medicare Benefits Schedule, this policy, and all applicable law.

The Department of Health considers the following to be Medicare abuse:

• Conduct that constitutes Medicare Fraud under Part IX of the Criminal Code Act;
• Claiming a Medicare payment for a treatment or service provided in furtherance of a criminal act; and
• Charging a patient a co-payment amount inconsistent with the Medicare Benefits Schedule.

Any abuse of Medicare constitutes a serious mishandling of Department resources and may result in disciplinary action, including termination of employment, revocation of licences, and referral for criminal investigation where appropriate.

Compliance with Medicare law and policy is a condition of employment and licensure within the Department of Health.

UPDATING THE MBS​

The Secretary of Health has access to the following commands for managing the MBS:

• /medicare list - Lists all treatments covered by the MBS.
• /medicare add <treatment> - Adds a treatment to the MBS.
• /medicare remove <treatment> - Removes a treatment from the MBS.
• /medicare set_benefit <treatment> <price> - Sets the benefit for a treatment on the MBS.
• /medicare benefit <treatment> - Checks the benefit paid out by medicare for any covered treatment

The secretary MUST update this policy and any guides or in-game signs as soon as reasonably possible after modifying the MBS.

The Medicare Policy is updated and enforced at the discretion of the Secretary. Any doubts, concerns or requests may be raised directly with the Secretary or Deputy Secretary.

Stay healthy!
​