CENTERS
FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
AUTHORIZATION:
Social
Security Act Amendments of 1965, Title XVIII, Part B, Public Law
89-97, as amended; Public Laws 90-248, 92-603, 93-233, 94-182, 95-210
and 95-292, 42 U.S.C. 1395 et seq.; Social Security Disability Amendments
of 1980, Public Laws 96-265 and 97-248; Section 1, Public Law 98-21;
Subtitle A, Public Law 98-369, as amended; Public Laws 98-460, 99-272,
99-509, and 100-203, 42 U.S.C. 1305 Note; Medicare Catastrophic
Coverage Repeal Act of 1988, Title I, Subtitle B, Title II, Subtitles
A and B, Title IV, Subtitle B and C, Public Law 100- 360; Medicare
Catastrophic Coverage Repeal Act of 1989, Title II, Public Law 101-234;
Omnibus Budget Reconciliation Act of 1989, 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; Health Insurance Portability
and Accountability Act of 1996, Public Law 104-191; Contract with
America Advancement Act of 1996, Public Law 104-121; Balanced Budget
Act of 1997, Public Law 105-33; Balanced Budget 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 medical insurance protection for covered services to persons
age 65 or over, to certain disabled persons and to individuals with
chronic renal disease who elect this coverage.
TYPES
OF ASSISTANCE:
Direct Payments for Specified Use. Place Cursor Here for Definition
USES
AND USE RESTRICTIONS:
Managed
care benefits are paid on the basis on Medicare capitation rates.
Fee-for-service benefits are paid on the basis of fee schedules
or other approved amounts for services furnished by physicians and
other suppliers of medical services to aged or disabled enrollees.
Benefits are paid on the basis of prospective payment system for
covered services furnished by participating providers such as hospitals
and home health agencies.
ELIGIBILITY
REQUIREMENTS:
Applicant
Eligibility: All persons who are eligible for
hospital insurance benefits (see 93.773) and persons age 65 and
older who reside in the United States and are either citizens or
aliens lawfully admitted for permanent residence who have resided
in the United States continuously during the five years immediately
preceding the month in the application for enrollment is filed,
may voluntarily enroll for supplementary medical insurance (SMI).
The beneficiary pays a monthly premium. In calendar year 2002, the
base premium is $54.00. Some States and other third parties may
pay the premium on behalf of qualifying individuals.
Beneficiary
Eligibility: Persons age 65 and over, and
persons under age 65 who qualify for hospital insurance benefits.
Credentials/Documentation:
Proof of age, disability or lawful admission status. 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. Most persons entitled to hospital insurance are
enrolled automatically for supplementary medical insurance. Since
the program is voluntary, you may decline coverage. Persons not
entitled to hospital insurance must file an application. This
program is excluded from coverage under OMB Circular Nos. A-102
and A-110.
Award
Procedure: After review of the application
is completed, the applicant will be notified by mail.
Deadlines:
Certain individuals may enroll during a special enrollment period
(SEP) if they are covered under a group health plan (GHP) when
first eligible to get Medicare: (1) individuals age 65 or older
who are covered under a GHP based on their own or a spouse's current
employment; and (2) disabled individuals under age 65 who are
covered under a GHP based on their own or any family member's
current employment. If the coverage of disabled individuals under
age 65 was not through a large group health plan (LGHP), that
is, a plan that covers employees of a least one employer that
normally employs at least 100 employees, no family member other
than a spouse qualifies for a special enrollment period. An SEP
enrollment may occur during any month the individual is covered
under the GHP based on current employment or, during the eight
month period that begins the first month after employment or GHP
coverage ends, whichever occurs first. Months of coverage under
the GHP based on current employment are excluded from the calculation
of the premium surcharge.
Range
of Approval/Disapproval Time: Not applicable.
Appeals:
Telephone or visit the local Social Security Office or the 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: 20-8004-0-7-571.
Obligations:
(Benefit Outlays) FY 01 $100,513,905,000; FY 02 est $105,289,000,000;
and FY 03 est $108,907,000,000.
Range
and Average of Financial Assistance:
Generally, with exceptions for certain services, the beneficiary
is responsible for meeting the annual $100 deductible before benefits
may begin. Thereafter, Medicare pays a percent of the approved
amount for the covered service. For many services, this percentage
is 80 percent. For other services, the percentage that Medicare
pays will vary from 100 percent to 50 percent depending upon the
category of service.
In fiscal year 2001, 37,550,000 persons were enrolled for supplementary
medical insurance. In fiscal year 2002, the number of enrollees
is estimated to be 37,934,000. In fiscal year 2003, the number of
enrollees is estimated to be 38,275,000.
REGULATIONS,
GUIDELINES, AND LITERATURE:
Code of Federal Regulations, Title 20, Parts 401, 405, and 422;
Title 42, Parts 401, 405, 407, 408, 410, 413, 416, and 417. "Your
Medicare Handbook," 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 listing of Regional Offices.
Headquarters
Office: Center for Beneficiary Choices, Centers
for Medicare & Medicaid Services, Room C5-19- 16, 7500 Security
Boulevard, Baltimore, MD 21244. Telephone: (410) 786-3418.
Web
Site Address: http://www.cms.hhs.gov/contracts
