Medicare is a nationwide health insurance program for the aged and certain disabled persons. Congress established the Medicare program in 1965, with Lyndon B. Johnson signing it into law on July 30, 1965. It provides health benefits to persons aged sixty-five and older who are eligible for Social Security benefits or retirement benefits under the railroad retirement system. Cal. Clinical Lab’y Ass’n v. Sec’y Health & Hum. Servs., 104 F. Supp. 3d 66, 70 (D.D.C. 2015) (citing Pub. L. No. 89-97, 79 Stat. 291 (July 30, 1965) (codified at 42 U.S.C. §§ 1395 et seq.)). In 1972, Medicare was expanded to cover the disabled, people with end-stage renal disease (ESRD) requiring dialysis or kidney transplant, and people 65 or older that select Medicare coverage.
Medicare consists of four distinct parts: Part A (Hospital Insurance, or HI; See 42 U.S.C. § 1395d); Part B (Supplementary Medical Insurance, or SMI; See id. § 1395k); Part C (Medicare Advantage, or MA; See id. §§ 1395w-21 to 1395w-28); and Part D (the prescription drug benefit). The program is administered by the Centers for Medicare & Medicaid Services (CMS). According to the Congressional Budget Office, total program outlays are estimated to reach about $714 billion in fiscal year 2018. Net federal outlays, after deduction of beneficiary premiums and other offsetting receipts, are expected to be close to $590 billion in 2018.
The best single resource for the general public when determining what is (and is not) covered is the annual Medicare & You booklet, although a coverage tool is now available online. One of the best resources for cutting edge issues relating to Medicare coverage is the Center for Medicare Advocacy website.
Medicare is administered by CMS within the U.S. Department of Health and Human Services (DHHS). Day-to-day program operations, including processing benefits and paying claims, are conducted by private Medicare contractors.
The Medicare program (Title XVIII of the Social Security Act) provides hospital insurance (HI), also known as Part A coverage, and supplementary medical insurance (SMI), also known as Part B coverage. Coverage for HI is automatic for persons aged 65 and older (and for certain disabled persons) who have insured status under Social Security or Railroad Retirement. Coverage for HI may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for SMI also requires payment of monthly premiums.
Medicare copays, coinsurance rates and deductibles cause most Medicare beneficiaries on traditional Medicare to purchase a Medicare Supplement or Medi-gap policy. Most supplements cover the majority of copays, coinsurance and deductibles, meaning that a Medicare beneficiary can budget his or her health care expense, knowing that it will (almost) never exceed the cost of his or her premium. Unfortunately, this presumes the Medicare beneficiary only needs acute care (e.g., hospitalization, physician services, etc.). Although many people mistakenly believe that Medicare pays for long-term care, it does a poor job in that regard because long-term care is considered custodial care rather than health care. Most long-term care expenses are paid with private funds or through the Medicaid program.
Medicare beneficiaries who have low income and limited resources may receive help paying for their out-of-pocket medical expenses from their State Medicaid program. There are various benefits available to “dual eligible” who are entitled to Medicare and are eligible for some type of Medicaid benefit. Coordination between the program allows Medicaid to supplement Medicare coverage by providing services and supplies that are available under their State’s Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the State’s payment limit. Medicaid can also cover additional services (e.g., nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids).
Limited Medicaid benefits may also be available to pay for out-of-pocket Medicare cost-sharing expenses for certain other Medicare beneficiaries. The Medicaid program will assume their Medicare payment liability if the patient is eligible for Medicaid. Qualified Medicare Beneficiaries (QMBs), with resources at or below twice the standard allowed under the SSI program and income at or below 100% of the Federal poverty level (FPL), do not have to pay their monthly Medicare premiums, deductibles, and coinsurance. Specified Low-Income Medicare Beneficiaries (SLMBs), with resources at or below twice the standard allowed under the SSI program and income exceeding the QMB level, but less than 120% of the FPL, do not have to pay the monthly Medicare Part B premiums. Qualifying Individuals (QIs), who are not otherwise eligible for full Medicaid benefits and with resources at or below twice the standard allowed under the SSI program, will get help with all or a small part of their monthly Medicare Part B premiums, depending upon whether their income exceeds the SLMB level, but is less than 135% of the FPL, or their income is at least 135%, but less than 175% of the FPL.
Individuals who were receiving Medicare due to disability, but have lost entitlement to Medicare benefits because they returned to work, may purchase Part A of Medicare. If the individual has income below 200% of the FPL and resources at or below twice the standard allowed under the SSI program, and they are not otherwise eligible for Medicaid benefits, they may qualify to have Medicaid pay their monthly Medicare Part A premiums as Qualified Disabled and Working Individuals (QDWIs)
Medicare’s Parts
- Part A
- Part B
- Medicare Advantage Plans (formerly Part C)
- Part D
Medicare Supplement Plans
Children’s Health Insurance Program
Affordable Care Act
Enrollment Periods
Medicare Appeals
Congressional Research Service (CRS) Reports
Medicare and You
Medicare and You is an annual publication prepared by Medicare. Click here for a copy of Medicare & You. This publication includes most of the basic information you need to understand your Medicare benefits. Medicare.gov now has a coverage tool you can use to determine whether your test, item or service is covered.
If you have questions about your coverage which are not answered in Medicare and You, then you can call 1-800-MEDICARE (1-800-633-4227). The TTY number is 1-877-486-2048. The Medicare website is www.medicare.gov.
Resources:
- CMS.gov
- Medicare.gov
- Your Medicare Coverage (at Medicare.gov)
- Internet Based Manuals
- Medicare Coverage Database
- National Coverage Decisions (NCD) Manual
- Acronyms used in the Medicare Program
- Center for Medicare Advocacy
- A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers (KFF)
- How Does Medicare Pay Hospitals?
- Hospital Discharge Planning and Medicare Patient Rights
- W. Cohen, Reflections on the enactment of Medicare and Medicaid (1985)
BLOG POSTS
Planning for Adult Children with Disabilities
Planning for Adult Children with Disabilities Childhood Disability Benefits assist disabled children and adults who became disabled prior to age 22. Most begin with Supplemental Security Income, which is a monthly cash payment for individuals with limited income and few resources. Because a parent’s income and resources are usually deemed available to the child, SSI […]
Medicare Secondary Payer law
Since 1980, Medicare pays after another responsible entity pays certain health care claims for Medicare beneficiaries. This is known as Medicare Secondary Payer (MSP). Although the issue arises in other contexts, for Elder Law Attorneys, it usually comes up when an injury claim or a worker’s compensation claim is resolved. For that reason, this post […]
2025 Medicare Part B Premium and Part A Co-Pays
On November 8, Medicare announced the 2025 premiums and Co-Pays. The standard monthly premium for Medicare Part B enrollees will be $185.00 for 2025, an increase of $10.30 from $174.70 in 2024. The annual deductible for all Medicare Part B beneficiaries will be $257 in 2025, an increase of $17 from the annual deductible of […]
Free Webinar on Medicare: August 13, 2024
On August 13, 2024, from 3pm to 4pm ET, the Center for Medicare Advocacy is hosting a free webinar titled: Medicare 101: Where to Begin and How to Make the Most of Medicare. Understanding Medicare is important – whether you are currently enrolled in Medicare, or you may qualify in the future. This presentation will […]
2024 Medicare Premiums and Deductibles
On October 12, 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2024 Medicare Part D income-related monthly adjustment amounts. The standard monthly premium for Medicare Part B enrollees will be $174.70 for 2024, an increase […]
Social Security Announces 2024 Increase
On October 12, 2023, the Social Security Administration announced that Social Security and SSI payments will increase by 3.2% in 2024. Federal benefit rates increase when the cost-of-living rises, as measured by the Department of Labor’s Consumer Price Index (CPI-W). The 2024 SSI rate will be $943 for individuals and $1,415 for eligible couples. This […]
Sometimes You Must Say No
Sometimes you just have to say No “No” isn’t a four-letter word. Saying “no” isn’t necessarily bad and you shouldn’t feel bad when you say it. Part of saying no means taking a stand. It can mean standing up to injustice. For example, our legal system is, for the most part, dependent on people saying […]
Leqembi Approved by FDA
The FDA has approved Leqembi (Lecanemab) for patients with mild dementia and other symptoms caused by early Alzheimer’s disease. Approval followed a determination that a confirmatory trial verified clinical benefit. Leqembi is the first amyloid beta-directed antibody to be converted from an accelerated approval to a traditional approval for the treatment of Alzheimer’s disease. In […]
Updated Fact Sheet on Medicare Nursing Home Benefit
Medicare includes a nursing home benefit of up to 100 days following a qualifying hospital stay. The Medicare rehabilitation benefit is per spell of illness. On reason we say “up to” is because the Medicare benefit is a rehabilitation benefit and it ends when the need for skilled therapy ends. Historically, that meant Medicare coverage […]
Medicare Open Enrollment
Medicare Open Enrollment takes place each year between October 15th and December 7th. During the Open Enrollment period, you can check to see whether you have the right Medicare plan to cover your physicians and pharmaceuticals. You can check to see whether a Medicare Advantage Plan would give you similar or better coverage for a […]
Elder Law and Special Needs Law News Roundup – 10-14-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
What is a Medicare Supplement Policy (Medigap policy)?
Medicare is a nationwide health insurance program for individuals aged 65 and over and certain disabled individuals. The basic Medicare benefit package (termed “original Medicare” in this report) provides broad protection against the costs of many health care services. However, Medicare beneficiaries may still have significant additional costs, including copayments, coinsurance, deductibles, and the full […]
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
On December 8, 2003, the President signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. 108-173. On November 22, 2003, the House of Representatives voted 220 to 215 to approve H.R. 1, the Medicare prescription drug and modernization conference agreement. The Senate voted 54 to 44 to approve the conference agreement on […]
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP) was created in 1997 to give health insurance and preventive care to nearly 11 million, or 1 in 7, uninsured American children. Many of these children came from uninsured working families that earned too much to be eligible for Medicaid. All 50 states, the District of Columbia, and the […]
Medicare and the Affordable Care Act
The 2010 Affordable Care Act (ACA) brought the Health Insurance Marketplace, a single place where consumers can apply for and enroll in private health insurance plans. It also made new ways for us to design and test how to pay for and deliver health care. Medicare and Medicaid have also been better coordinated to make […]
Medicare Appeals
There are five levels in the Medicare claims appeal process: Level 1: Your Health Plan. If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim. Level 2: An Independent Organization. If you disagree with the decision in Level 1, you may request a reconsideration by an independent […]
Medicare Congressional Research Service (CRS) Reports
For more programmatic information, please see reports published by the Congressional Research Service. CRS works exclusively for the United States Congress, providing policy and legal analysis to Committees and Members of both the House and Senate, regardless of party affiliation. Legislative History The following provides a brief legislative history for Medicare from the prior Green Book […]
Medicare Enrollment Periods
Initial Enrollment Period If you are receiving Social Security or Railroad Retirement Benefits, then you will automatically get Medicare Part A starting the first day of the month you turn 65. You have the option of enrolling in Part B, with the Initial Enrollment Period beginning three months prior to the month when you turn […]
What is Medicare Part D?
Medicare Part D was created as part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, with an effective date of January 1, 2006. It is designed to subsidize the cost of prescription drugs for Medicare beneficiaries in the United States. Medicare Part D was estabilshed as part of the Medicare Prescription Drug […]
What are Medicare Advantage Plans?
Medicare Advantage replaced prior programs, alternatively called Medicare+Choice or Part C, which originated in the Balanced Budget Act of 1997. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 altered those programs and renamed them as Medicare Advantage. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care […]
What is Medicare Part B?
Medicare part B is voluntary. All persons over age 65 and all persons enrolled in part A may enroll in part B by paying a monthly premium. The 2022 monthly premium is $170.10 (0r higher depending on your income). Part B covers medically necessary doctor’s services, outpatient care, home health services (those not covered by […]
What is Medicare Part A?
Part A provides most of your institutional coverage. It covers inpatient care in hospitals, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care services, home health care services and inpatient care in a religious nonmedical health care institution. Part A also covers blood. If the hospital uses a blood bank, […]
CMS Announces 2023 Medicare Parts A & B Premiums and Deductibles 2023 Medicare Part D Income-Related Monthly Adjustment Amounts
On September 27, 2022, the Centers for Medicare & Medicaid Services (CMS) released the 2023 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2023 Medicare Part D income-related monthly adjustment amounts. Medicare Part B Premium and Deductible Medicare Part B covers physician services, outpatient hospital services, certain […]
CMS Announces Lower Premiums for Medicare Advantage and Prescription Drug Plans in 2023
On September 29, 2022, CMS issued the following press release regarding 2023 premiums for Medicare Advantage and Prescription Drug Plans: The Biden-Harris Administration has made expanding access to health insurance and lowering health care costs for America’s families a top priority, and today, the Administration is announcing that people with Medicare will see lower premiums […]
Elder Law and Special Needs Law News Roundup – 9-23-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Update on Talevski v. Health and Hospital Corporation of Marion County
In our August 26, 2022, News Roundup, we reported that Talevski v. Health and Hospital Corporation of Marion County (HHC) was headed to the Supreme Court. The case concerns the rights of nursing home residents. The Plaintiff argued the nursing home violated his rights under the Federal Nursing Home Reform Act (FNHRA). The nursing home […]
CMS Virtual Workshops: List Published 9-21-2022
The Centers for Medicare and Medicaid Services (CMS) regularly records and posts informational workshops on a variety of subjects. For example, the workshop recorded on August 2, 2022, regarding Social Security addresses a range of retirement issues for students. To participate live, or to hear a previously recorded program, you will need to create a […]
Elder Law and Special Needs Law News Roundup – 9-16-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 9-9-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Articles – Week of September 9, 2022
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
Elder Law and Special Needs Law News Roundup – 9-2-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Articles – Week of September 2, 2022
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
Elder Law and Special Needs Law News Roundup – 8-26-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 8-19-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Articles – Week of August 19, 2022
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
Elder Law and Special Needs Law News Roundup – 8-12-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Can a nursing home resident leave for a family meal while covered under Medicare days?
Sometimes nursing home residents want to leave the nursing home to visit family or just get some fresh are. So can they do that while Medicare is paying for skilled therapy. This question was address in a November, 2019, blog post by the Center for Medicare Advocacy. The article cites footnote of the Medicare Benefit […]
Articles – Week of August 12, 2022
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
Elder Law and Special Needs Law News Roundup – 7-29-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Articles – Week of July 29, 2022
The following articles relating to Elder Care, Elder Law and Special Needs were found during the week of July 29, 2022: Health Related Articles: Barriers to and facilitators of ethical encounters at the end of life in a nursing home: an ethnographic study Home‐ and community‐level predictors of social connection in nursing home residents: A […]
Elder Law and Special Needs Law News Roundup – 7-22-2022
We regularly post links to news articles and other resources that related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles […]
Elder Law and Special Needs Law News Roundup – 7-15-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 7-8-2022
*** Note: This issue is abbreviated due to the July 4th Holiday *** We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited […]
Elder Law and Special Needs Law News Roundup – 7-1-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 6-24-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 6-17-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Medicare Beneficiary challenges Local Coverage Determination as conflicting with NCD
In Greenwald v. Becerra (D. D.C. June 7, 2022), a Medicare beneficiary who had lymphedema (a chronic medical condition that results in the accumulation of fluid in the subcutaneous tissues of his legs) and other medical conditions sought coverage for a pneumatic compression device (PCD). PCDs are durable medical equipment designed to treat patients suffering […]
Elder Law and Special Needs Law News Roundup – 6-10-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 6-3-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Elder Law and Special Needs Law News Roundup – 5-20-2022
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
