Authored By: North Mississippi Rural Legal Services
Medicare is a federal health care program that is available to certain groups of people regardless of financial status. Medicare was enacted by Congress in 1965 as Title XVIII of the Social Security Act. Originally, Medicare consisted of only Part A, the hospital in-patient benefit or hospital insurance. Part B, which now covers physician services, outpatient services, hospital care, physical therapy, ambulance trips, some home health care, durable medical equipment and prosthesis was later included in the Medicare program. In the past few years some home health benefits were added to Part B.
Medicare enrollment is automatic for recipients of Social Security Retirement or Railroad Retirement benefits. An application for Social Security Retirement or Railroad Retirement is considered to be an application for Medicare. Others may make a written application at the Social Security Administration Office. The initial enrollment period is a seven (7) month period beginning three months (3) before the person's 65th birthday, and ending three (3) months after the 65th birthday. A person who doesn't enroll during the initial enrollment period may enroll in a subsequent year during a general enrollment period (January - March each year). Monetary penalties apply to those who fail to enroll during the initial enrollment period.
Part A pays for hospital, skilled nursing facility (home) and home health benefits.
The Part A Premium is $316/month (2003) for those who have less than 30 quarters of Medicare-covered employment; $174/month (2003) for those who have 30-39 quarters of Medicare covered employment. Recipients of Social Security Retirement and Disability benefits and Railroad Retirement benefits are not charge a premium for Part A benefits.
The Hospital Deductible is $840 per benefit period (2003). (The patient pays this the first time admitted in the hospital per "Spell of Illness").
The doctors who always accept the Medicare approved charges are called participating physicians. Even those doctors who do not elect to become participating physicians can agree on a case-by-case basis to accept the Medicare approved charge.
Doctors who choose to opt out of Medicare may enter into private contracts with beneficiaries to provide Medicare-covered services at a rate set by the doctor. In exchange for being able to set their own rate schedules, doctors must agree to give up Medicare payments for all patients for two years after entering into the private fee arrangement. Doctors must also inform beneficiaries that they will not be reimbursed by Medicare or a Medicare supplemental policy for the services they will receive even though the services are covered by Medicare.
Prior to the enactment of the Balance Budget Act of 1997 by Congress, Medicare home health benefits included an unlimited number of home health visits. As of January, 1998, there is now a prior institutionalization requirement for Medicare Part A coverage of home health benefits, and a 100 visit coverage limitation per spell of illness. As of January, 1998, home health services may be provided under Part A of Medicare (I) after a discharge from a hospital or rural primary care hospital in which the individual was an inpatient for not less than 3 consecutive days before such discharge, if such home health services were initiated within 14 days after the date of such discharge, or (ii) after discharge from a skilled nursing facility in which the individual was provided post-hospital extended care services if such home health services were initiated within 14 days after the date of such discharge.
Additional coverage for home health services which do not meet these Part A coverage criteria and visit limitations are available now under Part B of Medicare.
Another important change brought about by the Balanced Budget Act was a provision that prohibits home health coverage if the sole skilled nursing service needed is the taking of a blood sample. This limitation became effective February 5, 1998.
One of the most important changes to the Medicare program brought about by the Balanced Budget Act of 1997 was the creation of the Medicare Plus Choice Program. This program offers some Medicare beneficiaries health care plan options in addition to traditional Medicare.
Beginning in November, 1999, all Medicare beneficiaries who live in area where Medicare + Choice Plans are offered, have to choose between original Medicare (tradition fee-for-service Medicare and a Medicare + Choice Plan. Medicare + Choice plans include Health Maintenance Organization (HMOs), preferred provider organizations (PPOs), provider sponsored organizations (PSOs), Medical Savings Accounts (MSAs) and private fee-for-Medicare.
The current ability to disenroll a plan from January 1 through June 30, 2002 will be phased out, so that by 2003 beneficiaries will only be able to disenroll from a Medicare + Choice Plan within the first three months of the year