CENTERS
FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
AUTHORIZATION:
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.
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. Place Cursor Here for Definition
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.
ELIGIBILITY
REQUIREMENTS:
Applicant
Eligibility: 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 $319. A reduced Part A premium
of $175 per month in 2002 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.
Beneficiary
Eligibility: Persons age 65 or over and qualified
disabled persons.
Credentials/Documentation:
Proof of age or disability. This program is excluded from coverage
under OMB Circular No. A-87.
Pre-application
Coordination: None. This program is excluded
from coverage under E.O. 12372.
Application
Procedure: 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.
Award
Procedure: The individual will be notified
by mail of enrollment, whether automatic or applied for.
Deadlines:
None.
Range
of Approval/Disapproval Time: Not applicable.
Appeals:
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.
Renewals:
Not applicable.
ASSISTANCE
CONSIDERATIONS:
Formula
and Matching Requirements: This program has
no statutory formula or matching requirements.
Length
and Time Phasing of Assistance: Not applicable.
POST
ASSISTANCE REQUIREMENTS:
Reports:
None.
Audits:
None.
Records:
None.
FINANCIAL
INFORMATION:
Account
Identification: 20-8005-0-7-571.
Obligations:
(Benefit Outlays) FY 01 $135,979,000,000; FY 02 est $141,432,000,000;
and FY 03 est $145,870,000,000.
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 2002, the beneficiary
is responsible for a $812 inpatient hospital deductible, a $203
per day coinsurance amount for the sixty through ninetieth day
of inpatient hospital care, a $406 per day coinsurance
amount for inpatient hospital care during the 60 lifetime reserve
days, and a $101.50 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 2001, 39,499,000 persons were protected. In fiscal
year 2002, we estimate that the number of persons protected will
be 39,869,000. In fiscal year 2003, the number of persons protected
is estimated to be 40,319,000.
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. "Your Medicare
Handbook," SSA-79- 10050, and other publications are available from
any Social Security Office without charge.
INFORMATION
CONTACTS:
Regional
or Local Office: Consult Appendix IV of the
Catalog for a listing of Regional Offices.
Headquarters
Office: 1-800-MEDICARE
Web
Site Address: http://www.cms.hhs.gov/contracts
