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What is Medicare

Posted by DONALD BISTRAN on July 12, 2010 at 7:33 PM

Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. The program also funds residency training programs for the vast majority of physicians in the United States. Medicare operates as a single-payer health care system.[1]

The Social Security Act of 1965 was signed into law on July 30, 1965, by President Lyndon B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card, and his wife Bess, the second.[2]

Contents [hide]

1 Administration

2 Taxes imposed to finance Medicare

3 Eligibility

3.1 Alternative Options

4 Benefits

4.1 Part A: Hospital Insurance

4.2 Part B: Medical Insurance

4.3 Part C: Medicare Advantage plans

4.4 Part D: Prescription Drug plans

5 Out-of-pocket costs

5.1 Premiums

5.2 Deductible and coinsurance

5.3 Medicare supplement (Medigap) policies

6 Payment for services

6.1 Reimbursement for Part A services

6.2 Reimbursement for Part B services

6.2.1 Office medication reimbursement

6.2.2 Medicare 10% Incentive Payments

7 Costs and funding challenges

7.1 Financial viability

7.2 Aging of the population

7.3 Fraud and waste

7.4 Estimated net Medicare benefits for different worker categories

8 Criticism

8.1 Entitlement question

8.2 Claims of socialism

8.3 Financial challenges

8.4 Quality of beneficiary services

8.5 Hospital accreditation

8.6 Graduate Medical Education

9 Legislation and reform

10 Legislative oversight

11 See also

12 References

13 External links

13.1 Governmental links - current

13.2 Governmental links - historical

13.3 Non-governmental links

 

[edit] Administration

Health care in the United States

Public health care

Federal Employees Health Benefits Program

Indian Health Service

Medicaid

Medicare

Military Health System / TRICARE

State Children's Health Insurance Program (SCHIP)

Veterans Health Administration

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Private health coverage

Health insurance in the United States

Consumer-driven health care

Flexible spending account (FSA)

Health reimbursement account

Health savings account

High-deductible health plan (HDHP)

Medical savings account

Managed care

Health maintenance organization (HMO)

Preferred provider organization (PPO)

Medical underwriting

--------------------------------------------------------------------------------

 

Health care law

Emergency Medical Treatment and Active Labor Act (1986)

Health Insurance Portability and Accountability Act (1996)

Medicare Prescription Drug, Improvement, and Modernization Act (2003)

Patient Safety and Quality Improvement Act (2005)

Patient Protection and Affordable Care Act (2010)

--------------------------------------------------------------------------------

 

State/municipal level reform

Fair Share Health Care Act

Healthy Howard

Healthy San Francisco

Massachusetts health care reform

Oregon Health Plan

 

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The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), administers Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and the Clinical Laboratory Improvement Amendments (CLIA). Along with the Departments of Labor and Treasury, CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Social Security Administration is responsible for determining Medicare eligibility and processing premium payments for the Medicare program.

The Chief Actuary of CMS is responsible for providing accounting information and cost-projections to the Medicare Board of Trustees in order to assist them in assessing the financial health of the program. The Board is required by law to issue annual reports on the financial status of the Medicare Trust Funds, and those reports are required to contain a statement of actuarial opinion by the Chief Actuary.[3][4]

Since the beginning of the Medicare program, CMS has contracted with private companies to operate as intermediaries between the government and medical providers.[5] These contractors are commonly already in the insurance or health care area. Contracted processes include claims and payment processing, call center services, clinician enrollment, and fraud investigation.

[edit] Taxes imposed to finance Medicare

Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount of wages, etc., on which the Medicare tax could be imposed each year.[6] Beginning January 1, 1994, the compensation limit was removed. A self-employed individual must pay the entire 2.9% tax on self employed net earnings, but may deduct half of the tax from the income in calculating income tax.[citation needed]

[edit] Eligibility

In general, all persons 65 years of age or older who have been legal residents of the United States for at least 5 years are eligible for Medicare. However, if neither they nor their spouse have paid Medicare taxes for a minimum of 10 years (40 quarters), then they must pay a monthly premium to be enrolled in Medicare.[7]

Medicare part 'A' premiums are waived if the following circumstances apply:

They are 65 years or older and U.S. citizens or have been permanent legal residents for 5 continuous years, and they or their spouse has paid Medicare taxes for at least 10 years.

or

They are under 65, disabled, and have been receiving either Social Security benefits or the Railroad Retirement Board disability benefits for at least 24 months from date of entitlement (first disability payment).

or

They get continuing dialysis for end stage renal disease or need a kidney transplant.

or

They are eligible for Social Security Disability Insurance and have amyotrophic lateral sclerosis (known as ALS or Lou Gehrig's disease).

The 24 month exclusion means that people who become disabled must wait 2 years before receiving government medical insurance, unless they have one of the listed diseases or they are eligible for Medicaid.

Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay for any drugs that are not covered by Part D.

In 2008, Medicare provided health care coverage for 45 million Americans,[8] making it the largest single health care payer in the nation.[citation needed] Enrollment is expected to reach 78 million by 2030, when the baby boom generation is fully enrolled.[8]

[edit] Alternative Options

If an individual has not yet met the Medicare eligibility requirements they may be able to enroll in alternative programs such as a temporary Health Insurance, a Medicare Bridge Plan, or a Travel Insurance policy if they recently moved to the USA.

[edit] Benefits

Medicare has four parts: Part A is Hospital Insurance. Part B is Medical Insurance. Medicare Part D covers prescription drugs. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity.

The original program was only Parts A and B. Part D was new in January 2006; before that, Parts A and B covered prescription drugs in only a few special cases.

[edit] Part A: Hospital Insurance

Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor's fees.

Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met:

1.A preceding hospital stay must be at least three days, three midnights, not counting the discharge date.

2.The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.

3.If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered.

4.The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc

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11 Comments

Reply DONALD BISTRAN
6:10 PM on September 15, 2010 
What is Medicare Blog Edit Categories Post New Entry « Back to Blog « Older Entry | Newer Entry » What is Medicare
Posted by Donald Bistran on July 12, 2010 at 4:33 PM delete edit

Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. The program also funds residency training programs for the vast majority of physicians in the United States. Medicare operates as a single-payer health care system.[1]

The Social Security Act of 1965 was signed into law on July 30, 1965, by President Lyndon B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card, and his wife Bess, the second.[2
Reply Brittany Hart
12:36 AM on November 2, 2010 
Hey Thanks for the good info Donnie
Reply DONALD BISTRAN
1:01 PM on November 2, 2010 
Donald Bistran says...
What is Medicare Blog Edit Categories Post New Entry « Back to Blog « Older Entry | Newer Entry » What is Medicare
Posted by Donald Bistran on July 12, 2010 at 4:33 PM delete edit

Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. The program also funds residency training programs for the vast majority of physicians in the United States. Medicare operates as a single-payer health care system.[1]

The Social Security Act of 1965 was signed into law on July 30, 1965, by President Lyndon B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card, and his wife Bess, the second.[2
Reply DONALD BISTRAN
3:03 PM on September 29, 2013 
Brittany Hart says...
Hey Thanks for the good info Donnie
Reply DONALD BISTRAN
3:08 PM on September 29, 2013 
[Donald Bistran]

[/Donald Bistran
your Welcome BRittany keep in touch?
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