Medicare
Currently, more than 35 million Americans are covered by Medicare. Medicare was established by the U.S. government in 1965 to provide health insurance benefits (both hospital and non-hospital) to people over 65. The program was expanded in July 1973 to include anyone who is entitled to monthly disability benefits for 24 consecutive months under Social Security or the Railroad Retirement plan. Patients with end-stage renal diseases (ESRD) who require a kidney transplant may also be eligible for Medicare after a specified waiting period following the beginning of treatment,
The Healthcare Financing Administration was established in 1977 to administer the rap-idly evolving Medicare program. Now known as the Centers for Medicare and Medicaid Services (CMS), it is headquartered in Baltimore and is divided into ten regional offices. Social Security Administration offices across the country take applications for Medicare and provide general information about the program.
The three criteria for automatic eligibility for Medicare are:
1. Age 65 or older
2. At least 40 quarters of employment, or approximately 10 years
3. U.S. resident or legal alien with 5 years' continuous legal residence in the United States and a 10-year work history
An individual who does not meet the criteria for automatic eligibility may enroll for Medi-care by paying the full premium, the amount of which changes in January of each year.
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Each recipient of Medicare is issued a Health Insurance Claims (HIC) number. This number is assigned according to the recipient's Social Security number and an identifying letter. The identifying letter designates how the beneficiary became eligible:
A Denotes the person who is eligible through the above criteria.
B Denotes the non-employed spouse. This spouse qualifies for Medicare at age 65 as long as the working spouse qualifies.
D?? Denotes widow of qualified wage earner.
T? Denotes "deemed insured." Those persons covered by special allowance of the Social Security Department (disabled 24 months and renal dialysis patients).
Other definitions are explained in the Medicare Assistance Manual available from your regional CMS office.
The Medicare program is divided into two parts: Part A and Fart B. In general, Part A covers hospital costs that are billed di rectly by a hospital, skilled nursing facility, hospice, or home health care agency. Part A coverage is automatic for anyone eligible for Medicare. Part B is a voluntary program for which Medicare subscribers must sign up and pay a premium. Part B covers professional fees, whether inpatient or outpatient, and such items as office visits and ambulance services.
CMS itself does not administer or pay Medicare claims. The federal government contracts with private insurance organizations to process Medicare claims from hospitals, doctors, and health care agencies, These payer organizations differ depending on whether they are processing Part A or Part B Medicare claims.