All about Medicare - 1

Know about Medicare part 1


Medicare – An operations study

Medicare is a federal plan which is an entitlement program administered by CMS (Health Care Financing Administration) for patients over age 65 years, certain disabled individuals, and those with end-stage renal disease.

Under the Social Security Act, two insurance programs were established in 1965: PART-A (hospital insurance) and PART B (voluntary medical insurance). Both Part-A and Part-B are available to persons entitled to Medicare benefits.

Eligibility and Entitlement

The following category of persons are entitled to Medicare benefits:

a) Individuals who are 65 years and above and have paid FICA (Federal Insurance Contributions Act) taxes or Railroad Retirement taxes for at least 40 calendar quarters (10 years).
b) Adults disabled before age 18 and Parents are either disabled or eligible for retirement Social Security benefits.
c) Disabled individuals who are entitled to Railroad Retirement or SS benefits due to disability. There is an additional 5-month waiting period for Medicare after disability has been determined.
d) Spouse of a deceased, disabled, or retired worker provided the individual is entitled.
e) Individuals of any age who receive dialysis or a renal transplant for End-Stage Renal Disease (ESRD): Entitlement begins the first day of the month after an individual begins renal dialysis. For those in self-dialysis training, entitlement begins with the first month of training. Entitlement begins the month the individual is admitted to the hospital for a renal transplant, provided that the transplant is performed within 2 months. If this does not occur, entitlement begins the second month before the month of the transplant

Part A benefits are automatically available to persons who fulfill the above requirements. There is no premium.

Part B benefits are voluntary and is available to persons who fulfill the above requirements only if they intimate the Social Security Administration of their intention to take it or not. Monthly premium of $45.50 is payable in this case. For this purpose the enrollment period is fixed.


For Individual of age 65 years and above

A person is considered eligible on the first day of the month in which he attains the age of 65 and is also eligible for social security or railroad retirement benefits. For e.g. Franklin Roosevelt’s 65th birthday is on March 14th 1999. He is eligible for benefits on March 1st 1999. His spouse is also eligible for benefits. Entitlement continues until his death or until the enrollee notifies Medicare in writing of his wish to terminate coverage. For Part B, benefits would be terminated on non-payment of premiums. Voluntary termination of coverage ends on the last day of the month following the month in which the notice to terminate was received. There is a grace period not exceeding 90 days for termination due to non-payment of premiums.

For Disabled individuals

Persons who are entitled to social security benefits or railroad retirement benefits due to disability are also entitled to Medicare benefits. Entitlement under social security disability also extends to disabled widows and widowers between the ages of 50 and 65, certain women age 50 or older entitled to mother’s benefits, and persons age 18 and over who receive social security benefits because they became disabled prior to reaching age 22. Persons who are 65 and above would not receive benefits under this category even if they are disabled. Coverage under this category begins 24 months after becoming entitled to social security or railroad retirement benefits. Entitlement begins the first day of 25th month of disability entitlement and terminates at the end of the month following the month in which disability entitlement ends or at the end of the month prior to the month in which the individual attains the age of 65.

End Stage Renal Disease (ESRD)

Individuals who have end stage renal disease are entitled to Medicare coverage if they are (1) entitled to monthly social security or railroad retirement benefits, or (2) currently insured for old age and survivors insurance benefits, or (3) spouses or dependents of entitled individuals and have end stage renal disease. Dependents of eligible individuals are also covered if they also have ESRD.

Part A benefits include
•Inpatient hospital care•Inpatient care in a skilled nursing facility
•Care in a psychiatric hospital (upto 90 days in a lifetime)
•Hospice care and respite care when a terminally ill patient can be admitted to a hospice. A hospice is a public or private organization that provides respite care, support and symptom management to terminally ill patients and their families.
•Nursing home care (patient spends at least 3 days as inpatient in a benefit period)
•Home health services such as intermittent nursing care and physical, occupational or speech therapy; part-time services of home health aides, medical supplies and equipment (no drugs)
. These patients are generally confined to their homes by injury or illness.

Part B benefits include

•Physician services including surgery, consultations, home, office and institutional services and supplies incidental to physician services; drugs and biologicals that cannot be self-administered; physician therapy; speech pathology; blood and blood transfusions.
•Outpatient hospital services, including outpatient diagnostic services and physical and occupational therapy or speech pathology services furnished by certain approved institutions and public agencies; outpatient physician and occupational therapy services (upto a monetary limit per calendar year) furnished by an independently practicing therapist in the patient’s home or the therapist’s office; hospital services furnished to outpatients in connection with a doctor’s services; outpatient (ambulatory surgery) and emergency hospital outpatient services.
•Diagnostic x-ray and laboratory tests and other diagnostic tests, including in certain cases, diagnostic x-rays taken in a patient’s home.
•X-ray, radium and radioactive isotope therapy.
•Durable medical equipment such as oxygen, hospital beds and walkers for use in the home whether furnished on a rental basis or purchased.
•Artificial devices (other than dental) such as pacemakers that replace all or part of an internal body organ, colostomy or ileostomy bags and related supplies are also covered; one pair of glasses or contact lenses after cataract surgery is covered if an intraocular lens has been inserted.
•Braces and artificial legs.•Rural and community health clinic services performed by licensed nurses and physician assistants plus similar services provided to homebound patients in certain areas.
•Certified registered nurse anesthetist (CRNA), nurse midwife and physician assistant srvices.
•Psychologist and social worker services provided in connection with a physician’s service.
•Limited chiropatic services, pediatric and optometric services.
•Ambulance service (when the patient’s condition rules out other means of transportation).
•Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies.

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