(The pdf for the issue in which this article appears is available for download at: Bifocal, Vol. 38, Issue 1.)
The Medicare Program
Medicare provides health insurance for persons age 65 and older and persons eligible for Social Security Disability benefits for 24 months or more (with some exceptions for earlier coverage). The federal statutes creating the program can be found in 42 U.S.C. § 1395 et seq. and the federal regulations are located at 42 C.F.R. § 400 et seq. The program and policy operations manuals can be found at https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms.html
The Medicare Program has four parts:
- Medicare Part A covers hospital services, skilled nursing facilities, and home health services. The enabling law is found in 42 U.S. Code §§ 1395c–1395i-5 and the regulations are at 42 C.F.R. § 406. The program and policy manuals can be found at https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912.html
- Medicare Part B covers physician services, some preventative services, ambulance services, and durable medical equipment. The statutes can be found at 42 U.S.C. §§ 1395j–1395w-6 and the regulations are located at 42 C.F.R. Part 414. The policy manuals can also be found at https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912.html
- Medicare Part C, also known as Medicare Advantage, creates private insurance plans in the form of HMO, PPOs and such that replace Medicare Part A and B for beneficiaries who chose to enroll in them. The enabling law is found in 42 U.S. Code §§ 1395w-21–1395w-29 and the regulations are located at 42 C.F.R. Part 422. The policy manual is found at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/mc86c11.pdf
- Medicare Part D, creates private insurance plans that provide prescription drug coverage for Medicare beneficiaries. The enabling law is found in 42 U.S. Code §§ 1395w-101–1395w-154 and the regulations are located at 42 C.F.R. Part 423. The policy manual is found at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf
Medicare Enrollment & Eligibility
Enrollment in Medicare is handled by the Social Security Administration (SSA). Eligible beneficiaries who are already receiving social security benefits are automatically enrolled in Medicare. There are three ways to be eligible for Medicare: (1) Age 65 or older; (2) Disability; or (3) ESRD (transplant or three months regular dialysis). Those who are not receiving Social Security benefits must actively enroll. The requirements for enrolling in the Medicare program can be found at 42 C.F.R. § 422.510.
The enabling statutes can be found in 42 U.S.C. 1395a(a), the regulations are found at 42 C.F.R. § 405 et seq., and the program and policy operations manuals can be found at https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms.html. By statute, Medicare may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment. See 42 U.S.C. § 1395y(a)(1)(A).
Medigap insurance is meant to work in tandem with the original Medicare program by paying for beneficiary cost-sharing and some other services not usually covered by Medicare. An individual must have Parts A and B to buy a Medigap plan. Federal law provides rights to purchase policies at certain times and state law can expand such rights. The federal regulations can be found at 42 C.F.R. § 403.206. The program and policy operations manuals can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c28.pdf. More information can be found at http://www.cgsmedicare.com/jc/pubs/pdf/chpt7.pdf.
Medicare Savings Programs (MSPs)
There are three Medicare Savings Programs:
- Qualified Medicare Beneficiary Program (QMB)
- Specified Low Income Medicare Beneficiary Program (SLMB)
- Qualified Individual Program (QI)
A useful chart for state-by-state MSPs Eligibility and Coverage in 2016 can be found at https://www.ncoa.org/wp-content/uploads/medicare-savings-programs-coverage-and-eligibility.pdf
Medicaid is a joint federal/state program that helps pay medical costs for some individuals with limited income and resources. State Medical Assistance office is responsible for determining eligibility and enrollment. Medicaid was created in the Social Security Act § 1902. The federal statutes creating the program can be found in 42 U.S.C. § 1396a et seq., the federal regulations are located at 42 C.F.R. § 435.121; 435.330; 435.631; 435.733. The State Medicaid Manual can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html
Medicare Advantage (MA)
MA plans are another way to access Medicare benefits. A company offering an MA plan contracts with and is approved by CMS to administer Medicare benefits. The federal regulations can be found at 42 C.F.R. Part 422. The Medicare Managed Care Manual can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html
The appeals process for Medicare Parts A and B can be found at https://www.cms.gov/Outreach-and-Education/MedicareLearningNetworkMLN/MLNProducts/downloads/MedicareAppealsprocess.pdfThe regulations for Determinations, Redeterminations, Reconsiderations, and Appeals under Medicare Parts A and B can be found at 42 C.F.R. Part 405, Subpart I. Additionally, Appeals under the Medicare Part B program specifically can be found at 42 C.F.R. Part 405, Subpart H. The Medicare Part C regulations for appeals can be found at 42 C.F.R. Part 422, Subpart M. The Medicare Part D regulations for grievances can be found at 42 C.F.R. Part 423, Subpart M.