CENTERS FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Social Security Act Amendments of 1965, Title XVIII, Part A, Public Law 89-97, as amended, Public Laws 90-248, 92-603, 93-233, 94-182, 94-437 and 95-292, 42 U.S.C. 1395 et seq.; Social Security Disability Amendments of 1980, Public Law 96-265; Public Law 97-248; Section 1, Public Law 98-21; Subtitle A, Public Law 98-369; Public Law 98-460, 99-177, 99-272, 99-509, and 100-203, 42 U.S.C. 1305 Note; Medicare Catastrophic Coverage Repeal Act of 1988, Title I, Subtitles A and B, and Title IV, Subtitle B and C, Public Law 100-360; Catastrophic Coverage Repeal Act of 1989, Public Law 101-234; Omnibus Budget Reconciliation Act of 1989, Title VI, Subtitle A, Public Law 101-239; Omnibus Budget Reconciliation Act of 1990, Public Law 101-508; Omnibus Budget Reconciliation Act of 1993, Public Law 103-66; Social Security Act Amendments of 1994, Public Law 103-432; Contract with America Advancement Act of 1996, Public Law 104-121; Health Insurance Portability and Accountability Act of 1996, Public Law 104-191; Balanced Budget Act of 1997, Public Law 105-33; Balanced Budget and Refinement Act of 1999, Public Law 106-113; Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Public Law 106-554; Medicare Prescription Drug, Improvement and Modernization Act of 2003, Public Law 108-173.Deficit Reduction Act of 2005, Public Law 109-171; Tax Relief and Health Care Act of 2006, Public Law 109-432.
To provide hospital insurance protection for covered services to persons age 65 or above, to certain disabled persons and to individuals with chronic renal disease.
Types of Assistance
Direct Payments for Specified Use.
Uses and Use Restrictions
Hospital insurance benefits are paid to participating and emergency hospitals, skilled nursing facilities, home health agencies, and hospice agencies to cover the prospective payment amount or reasonable cost of medically necessary services furnished to individuals entitled under this program.
Persons age 65 or over and certain disabled persons are eligible for hospital insurance protection. Nearly everyone who reached 65 before 1968 is eligible for hospital insurance, including people not eligible for cash Social Security benefits. A person reaching age 65 in 1968 or after, who is not eligible for cash benefits, needs some work credit to qualify for hospital insurance benefits. The amount of work credit needed depends on age. Hospital insurance (Medicare Part A) is also available to persons, age 65 or over, not otherwise eligible through payment of a monthly premium which is currently $393. A reduced Part A premium of $216 per month in 2006 is available to persons with 30 or more quarters paid into the social security system, as well as to their spouse, surviving spouse or divorced spouse. The reduction in Part A premium payments would also apply to the surviving spouse, or divorced spouse of an individual who had at least 30 quarters of coverage under the social security system. Federal employees began contributing toward Medicare hospital insurance coverage beginning January 1983. Employees who worked prior to 1983 and who were employed during January 1983 can receive credit toward establishing Medicare eligibility, if necessary, for prior non-contributory quarters of Federal employment. State and local government employees not already in Social Security-covered positions and hired on or after April 1, 1986 also contribute toward Medicare hospital insurance coverage. Although States may request agreements to cover individuals employed prior to April 1, 1986, no credit is given toward establishing Medicare entitlement for prior employment. Persons under age 65, who have been entitled for at least 24 months to Social Security disability benefits, or for 29 consecutive months to railroad retirement benefits based on disability, are eligible for hospital insurance benefits.
Persons age 65 or over and qualified disabled persons.
Proof of age or disability. This program is excluded from coverage under OMB Circular No. A-87.
Application and Award Process
None. This program is excluded from coverage under E.O. 12372.
Telephone or visit the local Social Security Office. Individuals entitled to Social Security or railroad retirement are enrolled without application. This program is excluded from coverage under OMB Circular Nos. A-102 and A-110.
The individual will be notified by mail of enrollment, whether automatic or applied for.
Range of Approval/Disapproval Time
Telephone or visit the local Social Security Office or Medicare payment organization responsible for the initial determination. The appeal process ranges from reviews of the initial determinations to formal hearings and, in cases meeting certain criteria, reviews by Federal Courts.
Formula and Matching Requirements
This program has no statutory formula or matching requirements.
Length and Time Phasing of Assistance
Post Assistance Requirements
(Benefit Outlays) FY 07 $204,535,620,000; FY 08 est $226,122,000,000; and FY 09 est $242,234,000,000.
Range and Average of Financial Assistance
Benefits may be paid based on the prospective payment amount or the reasonable costs of covered inpatient hospital services and based on the reasonable costs of covered post-hospital extended care services which are incurred during a benefit period. For benefit periods beginning in calendar year 2008, the beneficiary is responsible for a $1,024 inpatient hospital deductible, a $256 per day coinsurance amount for 61 through 90 days of inpatient hospital care, a $512 per day coinsurance amount for inpatient hospital care during the 60 lifetime reserve days, and a $128 per day coinsurance amount for days 21 through 100 of care in a skilled nursing facility. Home health services are paid in full.
In fiscal year 2006, 42,684,000 persons were protected. In fiscal year 2007, we estimate that the number of persons protected will be 43,356,000. In fiscal year 2008, the number of persons protected is estimated to be 44,190,000.
Regulations, Guidelines and Literature
Code of Federal Regulations, Title 20, Parts 401, 405 and 422; Title 42, Parts 400, 401, 405, 406, 409, 412, 417, and 418. " Medicare and You," SSA-79-10050, and other publications are available from any Social Security Office without charge.
Regional or Local Office
Consult Appendix IV of the Catalog for a listing of Regional Offices.
Center for Beneficiary Choices, Centers for Medicare and Medicaid Services, Room C5-19-16, 7500 Security Boulevard, Baltimore, MD 21244. Telephone: (410) 786-3418. 1-800-MEDICARE(1-800-633-4227).
Web Site Address
57.001, Social Insurance For Railroad Workers
93.246, Health Centers Grants for Migrant and Seasonal Farmworkers;
93.774, Medicare-Supplementary Medical Insurance
96.001, Social Security-Disability Insurance
93.770 Medicare-Prescription Drug Coverage
Examples of Funded Projects
Criteria for Selecting Proposals