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)
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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 […]
